Guidelines on

Benign Prostatic Hyperplasia
J. de la Rosette, G. Alivizatos, S. Madersbacher, C. Rioja Sanz, J. Nordling, M. Emberton, S. Gravas, M.C. Michel, M. Oelke,

© European Association of Urology 2006

1. BACKGROUND 1.1 Prevalence 1.2 Is BPH a progressive disorder? 1.2.1 Indicators of progression 1.2.2 Conclusions 1.2.3 References RISK FACTORS 2.1 For developing the disease 2.2 For surgical treatment 2.3 References ASSESSMENT 3.1 Symptom scores 3.1.1 International Prostate Symptom Score (I-PPS) 3.1.2 Quality-of-life assessment 3.1.3 Symptom score as decision tool for treatment 3.1.4 Symptom score as outcome predictor 3.1.5 Conclusions 3.1.6 Recommendations 3.1.7 References 3.2 Prostate specific antigen (PSA) measurement 3.2.1 Factors influencing the serum levels of PSA 3.2.2 PSA and prediction of prostatic volume 3.2.3 PSA and probability of having prostate cancer 3.2.4 PSA and prediction of BPH-related outcomes 3.2.5 Conclusions 3.2.6 Recommendation 3.2.7 References 3.3 Creatinine measurement 3.3.1 Conclusions 3.3.2 References 3.4 Urinalysis 3.4.1 Recommendation 3.5 Digital rectal examination (DRE) 3.5.1 DRE and cancer detection 3.5.2 DRE and prostate size evaluation 3.5.3 Conclusions and recommendations 3.5.4 References 3.6 Imaging of the urinary tract 3.6.1 Upper urinary tract 3.6.2 Lower urinary tract 3.6.3 Urethra 3.6.4 Prostate 3.6.5 References 3.7 Voiding charts (diaries) 3.7.1 Conclusions 3.7.2 References 3.8 Uroflowmetry 3.8.1 References 3.9 Post-void residual volume (PVR) 3.10 Urodynamic studies 3.10.1 Outcome 3.10.2 Conclusions 3.10.3 References 3.11 Endoscopy 3.11.1 LUTS caused by bladder outlet obstruction 3.11.2 Morbidity of urethrocystoscopy

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3.12 4.

3.11.3 Relationship between trabeculation and peak flow rate 3.11.4 Relationship between trabeculation and symptoms 3.11.5 Relationship between trabeculation and prostate size 3.11.6 Relationship between trabeculation and obstruction 3.11.7 Bladder diverticula and obstruction 3.11.8 Bladder stones and obstruction 3.11.9 Intravesical pathology 3.11.10 Conclusions 3.11.11 References Recommendations for assessment

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TREATMENT 4.1 Watchful waiting (WW) 4.1.1 Patient selection 4.1.2 Education, reassurance and periodic monitoring 4.1.3 Lifestyle advice 4.1.4 Conclusions 4.1.5 References 4.2 Medical treatment 4.2.1 5-Alpha reductase inhibitors Finasteride (type 2, 5-Alpha reductase inhibitor) Efficacy and clinical endpoints Haematuria and finasteride Side-effects Effect on PSA Dutasteride Combination therapy Conclusions References 4.2.2 Alpha-blockers Uroselectivity Mechanism of action Pharmacokinetics Assessment Clinical efficacy Durability Adverse effects Acute urinary retention Conclusions References 4.2.3 Phytotherapeutic agents Conclusions References 4.3 Surgical management 4.3.1 Indications for surgery 4.3.2 Choice of surgical technique 4.3.3 Perioperative antibiotics 4.3.4 Treatment outcome 4.3.5 Complications 4.3.6 Long-term outcome 4.3.7 Conclusions and recommendations 4.3.8 References 4.4 Lasers 4.4.1 Laser types 4.4.2 Right-angle fibres 4.4.3 Interstitial Laser Coagulation (ILC) 4.4.4 Holmium laser resection of the prostate (HoLRP) 4.4.5 Conclusions 4.4.6 References 4.5 Transrectal high-intensity focused ultrasound (HIFU)





4.8 5.

4.5.1 Assessment 4.5.2 Procedure 4.5.3 Morbidity/complications 4.5.4 Outcome 4.5.5 Urodynamics 4.5.6 Quality of life and sexual function 4.5.7 Durability 4.5.8 Patient selection 4.5.9 Conclusions 4.5.10 References Transurethral needle ablation (TUNA®) 4.6.1 Assessment 4.6.2 Procedure 4.6.3 Morbidity/complications 4.6.4 Outcome 4.6.5 Randomized clinical trials 4.6.6 Impact on bladder outflow obstruction 4.6.7 Durability 4.6.8 Patient selection 4.6.9 Conclusions 4.6.10 References Transurethral microwave therapy (TUMT) 4.7.1 Assessment 4.7.2 Procedure 4.7.3 The microwave thermotherapy principle 4.7.4 Morbidity 4.7.5 High-intensity-dose-protocol 4.7.6 Prostatic temperature feedback treatment 4.7.7 Durability 4.7.8 Patient selection 4.7.9 Conclusions 4.7.10 References Recommendations for treatment

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FOLLOW-UP 5.1 Watchful waiting 5.2 Alpha-blocker therapy 5.3 5-Alpha-reductase inhibitors 5.4 Surgical management 5.5 Alternative therapies ABBREVIATIONS USED IN THE TEXT






Benign prostatic hyperplasia (BPH) is a condition intimately related to ageing (1). Although it is not lifethreatening, its clinical manifestation as lower urinary tract symptoms (LUTS) reduces the patient’s quality of life (2). Troublesome LUTS can occur in up to 30% of men older than 65 years (3).



Although many epidemiological clinical studies have been conducted worldwide over the last 20 years, the prevalence of clinical BPH remains difficult to determine. A standardized clinical definition of BPH is lacking, which makes it intrinsically difficult to perform adequate epidemiological studies. Among the published epidemiological studies, some include probability samples from an entire country, while others represent agestratified random samples or enrol participants from general practice, hospital populations or responders to selective screening programmes. There is also a lack of homogeneity among these studies in the way in which BPH is assessed, with different questionnaires and methods of administration. Barry et al. have provided the histological prevalence of BPH, based on a review of five studies relating age to histological findings in human male prostate glands (4). Histological BPH was not found in men under the age of 30 years but its incidence rose with age, reaching a peak in the ninth decade. At that age, BPH was found in 88% of histological samples (4). A palpable enlargement of the prostate has been found in up to 20% of males in their 60s and in 43% in their 80s (5); however, prostate enlargement is not always related to clinical symptoms (2). Clinical BPH is a highly prevalent disease. By the age of 60 years, nearly 60% of the cohort of the Baltimore Longitudinal Study of Aging had some degree of clinical BPH (6). In the USA, results of the Olmstead County survey, in a sample of unselected Caucasian men aged 40-79 years, showed that moderate-to-severe symptoms can occur among 13% of men aged 40-49 years and among 28% of those older than 70 years (1). In Canada, 23% of the cohort studied presented with moderate-to-severe symptoms (7). The findings for prevalence of LUTS in Europe are similar to those in the USA. In Scotland and in the area of Maastricht, the Netherlands, the prevalence of symptoms increased from 14% of men in their 40s to 43% in their 60s (8,9). Depending on the sample, the prevalence of moderate-to-severe symptoms varies from 14% in France to 30% in the Netherlands (10,11). The proportion of men with moderate-to-severe symptoms doubles with each decade of life (10). Preliminary results of one of the most recent European epidemiological studies on the prevalence of LUTS show that approximately 30% of German males aged 50-80 years present with moderateto-severe symptoms according to the International Prostate Symptom Score (i.e. I-PSS > 7) (12). A multicentre study performed in different countries in Asia showed that the age-specific percentages of men with moderate-to-severe symptoms were higher than those in America (13,14). The prevalence increases from 18% for men in their 40s to 56% for those in their 70s (13). Curiously, the average weight of Japanese glands seemed to be smaller than those of their American counterparts (15). Despite methodological differences, some conclusions can be drawn from the studies mentioned above: • Mild urinary symptoms are very common among men aged 50 years and older. • Mild symptoms are associated with little bother, while moderate and severe symptoms are associated with increasingly higher levels of inconvenience and interference with living activities (16). • The same symptoms can cause different troublesome and daily living interference (17). • The correlation between symptoms, prostate size and urinary flow rate is relatively low (18). It must be stressed that there is still a need for an epidemiological definition of BPH and its true incidence has yet to be determined (19).


Is BPH a progressive disorder?

As it is almost impossible to obtain agreement on what it is that defines a man with LUTS/BPH, it seems logical to say that progression cannot be defined in terms of a transition from non-cases to cases. Instead, progression must be measured by documenting deterioration in any number of physiological variables that we associate with the LUTS/BPH syndrome. Traditionally these have included the following: • decrease in maximum flow rate • increase in residual volume • increase in prostate size • deterioration (increase) in symptom score. In addition, definable events, such as the occurrence of acute urinary retention or prostate surgery, have been used. Less commonly, changes in urodynamic variables and deterioration in disease-specific quality of life have been advocated. Considerable interest currently rests with PSA. It appears to be as good a predictor of progression as any of the variables mentioned above.



5-3. DRE = digital rectal examination. or none. N = no evidence.2. BPE = benign prostatic enlargement.9%d NR 10% over 4 years NR 10-39%e 2-year studies (30-34) North AmeNR NR rican (35) a Men with moderate to severe symptoms. Risk factors for progression were found to be age (Olmsted County).0 34. MRI = magnetic resonance imaging. AUR = acute urinary retention. QoL = quality of life.3 11. Qmax = maximum flow rate.1 Indicators of progression The strongest evidence to support progression comes from the Olmsted County (20) community-based study and the PLESS placebo group (21). they are very rare and therefore could not be evaluated accurately in community-based and clinical studies. The same strategy could be applied to patients who are at increased risk of progression based on recognised risk factors.3 in 4 yearsb NR -2% per year NR +0. such as symptom severity and decreased urinary flow rate. W = weak.9 NR NR 7% over 4 years 1. Table 1: Strength of evidence for specific parameters as indicators of progression of benign prostatic hyperplasia (BPH) Parameter IPSS BII QoL DRE TRUS MRI Qmax Histology AUR Surgery Crossover/treatment Community. The evidence for the progression of BPH has been summarised previously (22). PSA level and prostate volume.based studies S S N N S N S N/A S S S Clinical trials N/W* N/N W/S* N S S/S* W/S* N/A S/S* W/S* N LUTS BPE BOO BPH Miscellaneous *Conditional risk factors: age and prostate-specific antigen (PSA). but current data are not as convincing as those for age. LUTS = lower urinary tract symptoms. Table 2: Rates of progression of individual parameters in BPH Study Rate of progression LUTS Flow rate (points) Prostate size Olmsted (23-27) Health Professional (28) PLESS (29) 0. These parameters could potentially be used in decisions about treatment management. such as renal impairment and bladder dysfunction. Although these are important. weak. The strength of evidence for individual parameters as indicators of progression is summarised in Table 1 and is categorised as strong.18 per year NR -1. 6 UPDATE MARCH 2004 . Other baseline risk factors can be identified. Patients who show signs of more pronounced disease progression could be targeted for preventative strategies. PSA (PLESS) and prostate volume (combined 2-year placebo analysis).3 10. have been associated with progression of BPH. I-PSS = International Prostate Symptom Score. N/A = not available. S = strong. Several other complications.2 mL/s in 4 yearsb NR 1. TRUS = transrectal ultrasonography. The actual rates of progression of the individual parameters as determined from the papers reviewed is shown in Table 2.7 3.1. BII = BPH Impact Index.6-4.3 Surgerya (Incidence/1000 person years) > 70 40-49 years years 0.9% per year NR +14% in 4 years NR NR Acute urinary retentiona (Incidence/1000 person years) > 70 40-49 years years 3.2%c 0. BOO = bladder outlet obstruction.

J Urol 1994.Benign Prostatic Prevalence and detection of micturition problems among 2.2. Nordling J. J Urol 1984.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7685427& dopt=Abstract Donovan JL.nlm. J Urol 1995. The prevalence of prostatism: a population based survey of urinary symptoms. Oesterling JE.ncbi.nlm. REFERENCES Chute CG. Teillac P.nlm.ncbi. age. 10.nih. There are limited published data on longitudinal studies and the key pieces of evidence that support this notion are the Olmsted County and PLESS studies. Urology 1991.99:639-645.734 elderly men. Using the ICSQoL to measure the impact of lower urinary tract symptoms on quality of life: evidence from the ICS-‘BPH’ study. High prevalence of benign prostatic hypertrophy in the community.fcgi?cmd=Retrieve&db=PubMed&list_uids=7532230& dopt=Abstract 2.150:85-89.fcgi?cmd=Retrieve&db=PubMed&list_uids=1714657& dopt=Abstract Norman RW. UPDATE MARCH 2004 7 .gov/entrez/query. 9. Lancet 1991. Fozzard JL. Matos-Ferreira A. Nissenkorn I. Janknegt RA. Bosch JL. It might be appropriate to identify these patients at risk of progression and initiate early preventative treatment.15:669-673. BPH disease management. b 1. Harvard http://www. McFarlane G. Barbalias G.fcgi?cmd=Retrieve&db=PubMed&list_uids=7933185& dopt=Abstract Sagnier PP. NR = not reported. Girman dopt=Abstract Barry SJ. Gajewski JB.ncbi. Schick E. Natural history of benign prostatic hyperplasia and risk of prostatectomy. PSA level and prostate volume.ncbi.nlm. 7. Rentzhog L. Ewing LL.fcgi?cmd=Retrieve&db=PubMed&list_uids=7530115& dopt=Abstract Garraway WM. Coffey DS. 8. d According to baseline prostate-specific antigen (PSA) level. Pickett SN. http://www. Impact of symptoms of prostatism on level of bother and quality of life of men in the French c According to baseline prostate volume. 36(Suppl 3):1-6. Guess HA. 5. Prostate-related symptoms in Canadian men 50 years of age or older: prevalence and relationships among symptoms.nih.3 1. 4. J Urol 1993. Eur Urol 1. J Urol 1968. Fish D. Nickel JC.nih. Br J Urol 1994. 6.35(Suppl):4-8.fcgi?cmd=Retrieve&db=PubMed&list_uids=4171950& dopt=Abstract Arrighi HM.2. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=6206240& dopt=Abstract Lytton B.Flow rate and LUTS responded to placebo treatment by showing an initial improvement. http://www.nih. The incidence of benign prostatic Lieber MM. Guess HA. Collins GN. Silva MM. http://www. The development of human benign prostatic hyperplasia with age. Panser LA. Br J Urol 1997.nlm. Boyle P. http://www. Lee RJ. A group of patients at increased risk of progression can be identified based on specific risk factors. BPH can be considered a progressive disease. Emery http://www. Kay HE.nih.nih. Metter EJ. Botto H. Peters TJ. 3. http://www. which deteriorated back towards baseline during the course of the placebo-controlled trial. Walsh PC. Knottnerus JA.fcgi?cmd=Retrieve&db=PubMed&list_uids=9393291& dopt=Abstract Chapple CR.2 CONCLUSIONS Based on published data on consequences and complications of the disease. Coast J. International Continence Society .fcgi?cmd=Retrieve&db=PubMed&list_uids=1714529& dopt=Abstract Wolfs GGMC. Jacobsen SJ. the Baltimore Longitudinal Study of Aging.152:1467-1470.nih. de la Rosette JJ. http://www.132:474-479. Abrama P. Richard F.ncbi.nih. LUTS = lower urinary tract symptoms.nih.

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PROSCAR long term efficacy and safety group. Natural history of prostatism: risk factors for acute urinary retention. Saltzman B. http://www.ncbi. Andriole Walsh P.ncbi. Harrison LH. Bonilla J Rosenblatt S.ncbi. Urology 1999. Roehrborn CG.162:376-382. Waldstreicher J.nlm.nih. Jacobsen SJ. Longitudinal changes in peak urinary flow rates in a community-based cohort. PROSCAR longterm efficacy and safety Jacobsen DJ.53:473-480. McConnell JD. Fozard JL. Jacobsen SJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=10411042& dopt=Abstract McConnell JD.163:107-113. Castellanos R.nlm.nih.nih. http://www. Jacobson DJ. Oesterling JE. Schellhammer Roberts RO. Holtgrewe HL. Shown T.fcgi?cmd=Retrieve&db=PubMed&list_uids=9475762& dopt=Abstract Arrighi HM.ncbi. Nickel JC. Bergner D. Lieber MM. 27.39:390-399. randomized trial comparing finasteride versus placebo. 31.fcgi?cmd=Retrieve&db=PubMed&list_uids=10604304& dopt=Abstract UPDATE MARCH 2004 9 . Waldstreicher J Urol 2000. deVere White R. Gray T. Albertsen P. Lieber MM.fcgi?cmd=Retrieve&db=PubMed&list_uids=10510925& dopt=Abstract Roehrborn CG. Waldstreicher J. Roberts dopt=Abstract Rhodes T. Malek GH. Urology 1999. Giovannucci E.338:557-563. J Urol 1996. Finasteride Long-Term Efficacy and Safety Study Group. Treatment for benign prostatic hyperplasia among community dwelling men: the Olmsted County Study of urinary symptoms and health status. Emberton M. Girman CJ. Metter EJ.16:253-261. Waldstreicher J. J Urol 1999.nlm. The progression of benign prostatic hyperplasia: examining the evidence and determining the risk. http://www. PLESS Study Group Serum prostate-specific antigen and prostate volume predict long-term changes in symptoms and flow rate: results of a fouryear.163(Suppl 4): 249 [abstract 1105] Roberts RO.nih.nlm. Serum prostate-specific antigen is a strong predictor of future prostate growth in men with benign prostatic hyperplasia.nih. http://www. Matsumoto AM. Melman A. Kaplan S. J Urol 1999. 28. Guess HA. Coffield S. J Urol 2000.fcgi?cmd=Retrieve&db=PubMed&list_uids=11306876& dopt=Abstract Roehrborn CG. Roy J. Lieber M.155:595-600.ncbi. http://www. http://www. McConnell JD. Longitudinal prostate volume in a community-based sample: 7 year followup in the Olmsted County Study of urinary symptoms and health status among men. Gittelman M.ncbi. 30.163:13-20. Bruskewitz R. Taylor Resnick M. Walsh P. Taylor AM.nih. Rhodes T.nlm. 24. Rhodes T. Jacobson DJ.nih.162:1301-1306. Symptoms and signs of prostatism as risk factors for prostatectomy. Girman CJ. 29. Serum prostate-specific antigen is a powerful predictor of acute urinary retention and the need for surgery in men with clinical benign prostatic hyperplasia. http://www. Guess HA. Natural history of prostatism: longitudinal changes in voiding symptoms in community dwelling men. 25. Bruskewitz R. 34.fcgi?cmd=Retrieve&db=PubMed&list_uids=10604326& dopt=Abstract Meigs Lieber M. Eur Urol 2001. Incidence rates and risk factors for acute urinary retention: the Health Professional Followup Study. Cook TJ.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=1691843& dopt=Abstract Anderson JB. Jacobsen SJ. Kawachi I. http://www. New Engl J Med 1998. Bracken RB. Geller J. Rimm EB. PLESS Study Group. Malek GH. Lieber MM. 26.158:481-487.ncbi. PLESS Study Group.ncbi.nih. PLESS Study Group. Fuselier Prostate 1990. Andriole G.fcgi?cmd=Retrieve&db=PubMed&list_uids=10492184& dopt=Abstract Jacobsen SJ.ncbi. Guess HA. Boyle P. Stampfer MJ. Roberts RO. Rhodes T. Roehrborn Hudson PB. Jacobson DJ.nlm. Girman http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=10510925& dopt=Abstract Roehrborn CG. Schalken JA.nih. Resnick M. Wang DZ. Girman CJ. Girman CJ. Wang D. http://www. Rhodes T. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. J Urol 2000. Lieber MM. Guess HA. Barry MJ. J Urol 1997.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9224329& dopt=Abstract Jacobsen SJ. 33.nih. Lieber MM. http://www.

Adriole GL. sensation of incomplete voiding and digital rectal enlargement of the prostate. Walsh PC. In the Veterans Normative Aging Study. they still represent the second most common major operation in aged men (7). the fact that both conditions increase with age and can cause partially similar voiding symptoms. the likelihood of being treated surgically is about 3% (8. vasectomy.3 for hesitancy in young men (aged < 65 years). From the above.nih. Men with one factor had a cumulative incidence of surgery of 9%. Nocturia and changes in urinary stream seem to be the most important predictive symptoms. REFERENCES Oishi K. Imperato-McKinley J. http://www.327:1185-1191. 2. New Engl J Med 1992 Oct 22. the cumulative incidence for prostatectomy is 60% at 1 year and 80% at 7 years (11). and a history of kidney X-ray and/or tuberculosis. 10 UPDATE MARCH 2004 . Nevertheless. In: Denis L.1 RISK FACTORS For developing the disease The aetiology of BPH is multifactorial. only nocturia (odds ratio 2. those with two factors of 16%.4) was predictive of surgery (13). produces a considerable bias (3). and those with three factors of 37%. http://www.280 Boyle P.9). July 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=7519437& dopt=Abstract 2.8 for nocturia and 4. with a mean follow-up of 12 years.nlm. Plymouth: Health Publications. Gormley GJ. the main predictor for surgery was the presence of urinary symptoms. Recently. Tenover JS et urine pH greater than 5. Bracken BR. nonsmokers. three in 10 men may undergo surgery for this condition (2). Boyle P. there is no strong evidence that smoking. low body mass index. Multivariate analysis carried out on a sample of 16. Both of these risk factors are currently beyond prevention. for each of the five clinical urinary symptoms studied (12). The Finasteride Study Group. The need for surgery increases with symptoms and is twice as high in men with a high baseline-symptom score than for those with a low score (10). In most cases only insufficient marginal differences can be established (1). 2.3). Paris. Epidemiology and natural history of benign prostatic hyperplasia. The only true factors related to the development of the disease are age and hormonal status (4). Among older men.ncbi. showed a positive association with surgery for age. the three predictive symptoms for surgery were change in size and force of the urinary stream. such as hypertension or diabetes. The crucial role of the testis has been recognized for more than a century and current research has extended into the field of molecular biology (5). but given the frequent occurrence of these conditions in ageing men a large proportion of patients can be expected to suffer from such an association (2. Although more severe BPH symptoms (increased I-PSS and post-void residual) seem to be found in diabetic males even after age adjustment. Fourth International Consultation on BPH. it can be concluded that the risk of needing surgery for BPH increases with age and with the degree of clinical symptoms at baseline.2 For surgical treatment Although the number of surgical procedures for BPH has declined in the USA and Europe over the last decade (6).35. Stoner E. For men presenting with urinary retention.ncbi. Ultimately. Br J Clin Pract 1994. the odds ratio being 1. The effect of finasteride in men with benign prostatic hyperplasia. In the absence of clinical symptoms. probably because of differences in sampling and methods of analysis.74(Suppl):18-22. http://www. pp. Results of the different epidemiological studies are controversial.219 men. Bruskowitz RC. 25-59. the same study showed that increasing age was the predominant risk factor for surgery (8). aged at least 40 McConnell JD.3 1. have been related to clinical BPH. In the Baltimore study. eds. Chronic conditions. Surgical risk depends on age and the presence of clinical symptoms. in a cohort of 2. Currently. Barry JM et al. Epidemiology of benign prostatic hyperplasia: risk factors and concomitance with hypertension.fcgi?cmd=Retrieve&db=PubMed&list_uids=1383816& dopt=Abstract 2. The risk of requiring subsequent surgery also varied with age. 2. obesity or high alcohol intake are risk factors in the development of clinical BPH. Khoury S et al. it has been stated that diabetes and clinical BPH are associated more frequently than would be expected based on chance alone. 1998. Geller J. Griffiths K.

Cattolica EV. bother and quality of life (Table 3) (1). de Labry L. Molecular genetics of benign prostatic hyperplasia.ncbi. http://www.isismedical. 51-70.plymbridge. pp.nlm. Barry MJ.. Prostate 1989. Fozzard JL. pp. http://www.334:75-79. Henderson WG. eds. Natural history of benign prostatic hyperplasia and risk of prostatectomy. Textbook of Benign Prostatic Hyperplasia.fcgi?cmd=Retrieve&db=PubMed&list_uids=7527493& dopt=Abstract Craigen A. N Engl J Med 1994. Goepel M. In: Kirby R et 8. 7. Etiology and disease process of benign prostatic hyperplasia. In: Kirby R et al. J Urol 2000. Textbook of benign prostatic Arrighi HM. 12.35(Suppl):4-8.fcgi?cmd=Retrieve&db=PubMed&list_uids=1714657& dopt=Abstract Diokno A.fcgi?cmd=Retrieve&db=PubMed&list_uids=2482772& dopt=Abstract Voller MC. in other words they measure what they UPDATE MARCH 2004 11 . 13.ncbi.ncbi. Sadler MC.ncbi.nlm. 9. http://www. Herzog A. Ackermann R. J Urol 1992. Lydick EG.isismedical.148:1817-1821. http://www. 11.fcgi?cmd=Retrieve&db=PubMed&list_uids=1714659& dopt=Abstract 3. http://www. Urology 1991.nlm.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1279223& dopt=Abstract Wasson J. In: Cockett ATK et al.nlm. Saunders C.163:1725-1729. Age-related differences in risk factors for prostatectomy for benign prostatic hyperplasia: the VA Normative Aging Study. Effect of diabetes on lower urinary tract symptoms in patients with benign prostatic hyperplasia. Keller AM.ncbi.3. 38(Suppl 1):9-12. Oxford: Isis Medical Media. Schumacher Meigs JB. pp. Lydick E. Risk factors for surgically treated benign prostatic hyperplasia in a prepaid health care plan. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate.nih.nlm. 4. 6. Reda 3. Holtgrewe HL. Schalken JA.18:226-232. Report from the Committee on the Economics of BPH..nlm.ncbi. Oxford: Isis Medical Media. Guess HA. http://www.nlm. Goldstein N. 125-135. Jersey: Scientific Communication International. J R Coll Gen Pract 1969.fcgi?cmd=Retrieve&db=PubMed&list_uids=4186545& dopt=Abstract Sidney S. Metter EJ. reliability and responsiveness. Most instruments in current use conform to acceptable standards of validity. the Baltimore Longitudinal Study of Aging. The natural history of prostatic obstruction: a prospective survey. eds.(Suppl 2):33-50. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. Third international consultation on benign prostatic hyperplasia (BPH).gov/entrez/query. 109-113. 5. 1996. http://www.1 Symptom scores Probably the best way to assess symptom severity is with a validated symptom score. Mehlburger L. Vokonas PS. ASSESSMENT Diagnostic investigations have been classified as: • recommended: there is evidence to support the use of this test • optional: this test is done at the discretion of the clinician • not recommended: there is no evidence to support the use of this test. http://www. Bay-Nielsen H et al. Natural history of benign prostatic hyperplasia. Hickling J.nih. Urology 1991. Carpenter R.nih. Urology Brown M. Michel Bressel HU. http://www. 1996.nlm.nih. A number of instruments exist that can measure symptom dopt=Abstract Isaacs JT. Guess HA. Coffey DS. Elinson J. 10.38(Suppl 1) 1996. eds.nih. Bruskewitz RC. Quesenberry C Jr.nih..fcgi?cmd=Retrieve&db=PubMed&list_uids=1714653& dopt=Abstract Epstein RS. Epidemiology of bladder emptying symptoms in elderly men.

3. The authors suggested that patients with mild symptoms were most appropriately managed by a watchful waiting approach. The I-PSS appears less reliable in men over 65 years old (6) and careful linguistic validation needs to be undertaken prior to its use in non-North American cultures (7). Correlations of similar magnitude have been seen in many other disease areas. the Medical Outcomes Study. 3. This lack of correlation has troubled many investigators and has led to some questions raised about the validity of the I-PSS. Patient with moderate symptoms might benefit from pharmacotherapy. and in both predicting and monitoring the response to therapy. 8-10). Men report nocturia with accuracy but tend to overstate daytime frequency.1. post-void residual volume.3 Symptom score as decision tool for treatment Can symptom severity alone be used to allocate treatment? The US Agency for Health Care Policy and Research Guidelines (1) tried to do this.1. a postal population survey among 217 men aged 55 years and over with LUTS showed that. For example.purport to measure. which will also result in poor correlation.g. Secondly. quality-of-life instruments have been used for clinical research. 3. 3. peak respiratory flow correlates poorly with patient’s own reports of the severity of their asthma. The lack of correlation can be explained in two ways. There is little evidence that physiological measures improve the chances of predicting a favourable symptomatic outcome. e.1 International Prostate Symptom Score (I-PSS) The I-PSS has become the international standard. Increasing symptom severity was associated with worsening physical condition. It is derived from the American Urological Association (AUA) 7 score described by Barry and his colleagues in the early 1990s (3). Although notions of appropriateness have not been well-studied. By adding the scores (with equal weighting) to its constituent questions.1. average flow rate. are stable over time and are able to reflect clinically important changes (2). Three categories of symptom severity were described: mild (0-7). mental health and perception of general health. prostate size or pressure-flow relationships (1. I-PSS and physiological measures measure different things. has an 87% chance of experiencing a substantial symptom reduction (17). social functioning. 12 UPDATE MARCH 2004 . 3. a 36-item short-form health survey (SF36) (14). a summary or index score is generated which has been shown to be an accurate reflection of a man’s overall symptoms over the preceding month (4). It is a self-completed questionnaire used to measure general health status and quality of life. moderate (8-19) and severe (20-35).1. or more. vitality. Age and cultural factors may be important. A man with a pre-operative I-PSS of 17. A validated symptom score assesses symptom severity. Numerous authors have reported and commented upon the poor correlations between I-PSS and other physiological variables. Increasing ‘bothersomeness’ was associated with a worsening of all dimensions of general health status and quality of life.1. The association between the outcome of this population survey and the degree of ‘bothersomeness’ was stronger than that with the I-PSS symptom score. Using this score.4 Symptom score as outcome predictor Symptom score may be one of the more powerful predictors of symptomatic outcome (16). Correlation of the self-reported score to intermittency or to the strength of stream was poor (5).5 Conclusions Evaluating symptom severity with a symptom score is an important part of the initial assessment of a man. The extent to which the selfreported scores reflect actual events has been questioned. It is helpful in allocating treatment. It has been used in a number of studies addressing men with lower urinary tract symptoms. As men with mild symptoms have little room for improvement it is of little surprise that they do not experience high levels of symptom reduction following surgery. there are statistical issues related to the clustering of values or data points. Firstly.2 Quality-of-life assessment The impact of urinary symptoms on the quality of life is generally evaluated by means of question 8 of the I-PSS. One of the best known is the generic measure. A number of health-related. 9-49% of those with moderate or severe urinary symptoms reported interference with some of their daily activities. depending on the respondent’s activity. It can be used to monitor change in symptoms over time or following an intervention. However. the proposed policy appears to hold true for patients with mild symptoms but is less reliable for men with moderate or severe symptoms (15). there are numerous reports of symptom severity (as expressed by I-PSS) correlating poorly with peak urinary flow rate. this question measures the extent to which patients tolerate their symptoms rather than evaluating their quality of life. while patients with severe symptoms may derive most benefit from prostatectomy.

PSA and DRE . Roehrborn et al. 3. infection. At the same time. For many years the value of 4ng/mL was considered as the upper normal limit of PSA (10) but lately a lower threshold of PSA for recommending prostate biopsy in younger men has shown to improve the clinical value of this test (11). These nomograms are being constructed from variables such as age. may influence serum PSA levels the level of PSA correlates with the volume of the prostate gland the higher the PSA level.2. elevated free PSA levels could predict clinical BPH.1. the greater is the probability of having prostate cancer the PSA level might predict the natural history of BPH.3). since only minor variations in PSA reference ranges were found (5).054 men.2. but organ-specific. log-linear relationship and that PSA has a good predictive value for assessing prostatic volume (7). PSA density and TRUS findings (13.2 PSA and prediction of prostatic volume Stamey et al. (12) have used three clinical parameters .4 PSA and prediction of BPH-related outcomes In a series of studies. predictive nomograms have been developed by various groups. age.age. also found that prostate volume and serum PSA are significantly correlated and increase with advanced age (8). PSA.2.6 RECOMMENDATION The measurement of PSA is recommended when a diagnosis of prostatic carcinoma will change the decision made about which therapeutic option to use. e. Potter et al. must also be considered when evaluating PSA values in men with LUTS (2. every urologist will perform a DRE and most will measure the serum value of PSA. In order to avoid unnecessary biopsies. In their studies in the late 1980s.14).2. In a recent epidemiological study. Both PSA forms were found to be able to predict the TRUS prostate volume (± 20%) in more than 90% of the cases (9). 3. These parameters were also related with long-term changes in symptom scores and flow rates. 3. and therefore age-specific reference ranges must be adapted and interpreted according to race and ethnicity (4). (15. family history. age and race.and have calculated the likelihood of detecting prostate cancer on sextant TRUS-guided biopsies among 2. race. In addition. have shown that PSA and prostate volume have an agedependent. A recent community-based study of African-American men contradicts the beliefs of racial PSA differences. BPH. UPDATE MARCH 2004 13 . prostatitis and after urinary retention.6 RECOMMENDATIONS Recommended investigations: • Clinical history • Symptom assessment • Physical examination • Validated symptom score.2 Prostate-specific antigen (PSA) measurement Before selecting the proper treatment for men with LUTS. I-PSS 3. Prediction of prostate volume can also be based on total and free PSA. Vesely et al.5 • • • • Conclusions various factors (cancer.2. Roehrborn et al. This is why PSA is not considered as being cancer-specific.5 ng/mL per cm3 of cancer tissue. This occurs when prostatic carcinoma is present but also in BPH.1 Factors influencing the serum levels of PSA In cases where the architecture of the prostatic gland is disrupted.2.3 PSA and probability of having prostate cancer The chance of having prostate cancer is strongly related with the serum value of PSA. trauma. 3.30 ng/mL per gram of tissue and 3. Two other important factors. independent of total PSA levels (17). they found that the serum PSA contribution from BPH was 0. African-Americans with no evidence of prostate carcinoma have higher PSA values after their fourth decade of life.3. were the first to correlate PSA serum values and volume of prostatic tissue (6). DRE.g. PSA will ‘leak’ into the circulation. 3. Other known causes of PSA serum elevations are biopsy of the prostate gland and ejaculation (1). small and clinically insignificant changes occur after DRE. 3.16) have shown that PSA and prostatic volume can be used to evaluate the risks of either needing surgery or developing acute urinary retention.

Age-specific distribution of serum prostate-specific antigen in a community-based study of African-American Togami J. http://www.53:581-589.nlm. N Engl J Med 1987.nih. Kuntz KM. 8.nih. http://www. 9. Dahlstrand C. N Engl J Med 2001.nlm. Racial variation in prostate specific antigen in a large cohort of men without prostate cancer. Jacobsen SJ. Dicuio M. Alcser KH.2.fcgi?cmd=Retrieve&db=PubMed&list_uids=11394329& dopt=Abstract Cooney KA. Knutson T. Taylor A.37:322-328. 14 UPDATE MARCH 2004 . Chute CG. Encabo G. Alivizatos G.ncbi.nlm. 7. Horniger W.ncbi. Barrera E. Prostate specific antigen and benign prostatic hyperplasia.nih.ncbi. Prostate specific antigen. prostate-specific antigen.ncbi.ncbi. Urology 1997. symptom score and uroflowmetry in men with lower urinary tract symptoms. Brawer MK. http://www. Babaian RJ. Age. prostate volume.98:1849-1854. http://www.nih.nlm. Schottenfeld D.ncbi. Effect of verification bias on screening for prostate cancer by measurement of prostate-specific antigen. Effect of ejaculation on serum total and free prostate specific antigen concentrations. Wojno KJ. http://www. Taylor JM.fcgi?cmd=Retrieve&db=PubMed&list_uids=12944191& dopt=Abstract Morote J. Mori M.nih. laboratory.fcgi?cmd=Retrieve&db=PubMed&list_uids=14584066& dopt=Abstract Garzotto M.157:1100-1104.nih. Sullivan J. REFERENCES Herschman JD. Smith DS.nlm. 3. 10.7 1. Doerr KM. 13. Lieber MM.10:3-8.98:1417-1422. Partin A. Waldstreicher J. Urology Moparty B. 14. Cancer 2003. Panser LA.57:91-96.nih. Gould AL. Damber JE.fcgi?cmd=Retrieve&db=PubMed&list_uids=11333995& dopt=Abstract Punglia RS. Heeringa SG. http://jama.ncbi. http://www. http://www. 12. Niederberger CS. Hudson RG. http://www. J La State Med Soc Peters L.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=10096388& dopt=Abstract Vesely S. http://www. Curr Opin Urol 2000. Hsieh YC.fcgi?cmd=Retrieve&db=PubMed&list_uids=10859448& dopt=Abstract Barry MJ. Partin AW.nih.nlm. Predictive modelling for the presence of prostate carcinoma using Freiha FS. Catalona WJ. Redwine E. Tinzl M.153:184-189.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377318& dopt=Abstract Kalra P. Cancer 2003. Hay AR.349:335-342.nlm. Ross LS.nlm. N Engl J Med.50:239-243. Boyle P. http://www. Klein http://www. Bansal Laguna P.nlm. Wei JT. Girman CJ. Montie Prediction of prostate volume based on total and free serum prostate specific antigen: is it reliable? Eur Urol 2000.nih. Sartor O. Urology A neurocomputational model for prostate carcinoma detection.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=2442609& dopt=Abstract Roehrborn CG. Richey W. 5. Urology 200.nih. Scand J Urol Nephrol. 2003. Serum prostate specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia. and ultrasound parameters in patients with prostate specific antigen levels</= 10 ng/mL.fcgi?cmd=Retrieve&db=PubMed&list_uids=12878740& dopt=Abstract Potter SR. D’ Amico AV. 11. Testing for early diagnosis of prostate cancer. Lopez M. Serum prostate specific antigen in a community-based population of healthy men: establishment of age-specific reference ranges. JAMA 1993. Roehl KA.317:909-916. de Torres IM. Relationship between age. Guess HA.fcgi?cmd=Retrieve&db=PubMed&list_uids=11164150& dopt=Abstract Stamey TA.3.fcgi?cmd=Retrieve&db=PubMed&list_uids=10650506& dopt=Abstract Eastham JA. Bartsch G.fcgi?cmd=Retrieve&db=PubMed&list_uids=9255295& dopt=Abstract Oesterling JE. McNeal JE.344:1373-1377.ncbi.nih.nlm.38:91-95. Yang N. Strawderman MS. Prostate specific antigen as a serum marker for adenocarcinoma of the prostate. Catalona WJ.ama-assn. prostate specific antigen and digital rectal examination as determinants of the probability of having prostate cancer. Beer TM.fcgi?cmd=Retrieve&db=PubMed&list_uids=14508828& dopt=Abstract 2.nih.ncbi.

fcgi?cmd=Retrieve&db=PubMed&list_uids=11908420& dopt=Abstract 2.nih. 3. (10) studied the additional value of renal ultrasonography in the assessment of patients with BPH and concluded that only those with an elevated creatinine level needed such an investigation.3 Creatinine measurement It is well-accepted today that bladder outlet obstruction due to BPH might cause hydronephrosis and renal failure (1).fcgi?cmd=Retrieve&db=PubMed&list_uids=12121721&dopt=Abstract Roehrborn CG. Will EJ. Late renal failure due to prostatic outflow obstruction: a preventable disease.ncbi. proper therapy can be offered to the right men and the costs of long-term renal damage and post-surgical complications can be avoided. This study suggests that it is not necessary to control the serum creatinine if voiding is normal. McConnell JD. REFERENCES Sacks SH. Girman CJ. Cockett AT. as measured by an improvement in quality of life.fcgi?cmd=Retrieve&db=PubMed&list_uids=11520654& dopt=Abstract 3. In this way. Bruskewitz et al.3.nlm. Gray However. Oliver DO.nih. PLESS Study Group. the measurement of creatinine is highly recommended. these figures might be overestimates as these studies involved patients undergoing surgical treatment (i. Bergner D. (9) also found that an isolated serum creatinine level could not predict the outcome after TURP. http://www. A comparative study of 13 participating institutions evaluating 3. UPDATE MARCH 2004 15 . http://www. as the use of certain α-blockers might cause additional problems in men with renal insufficiency.2 1.nih.1 CONCLUSIONS As it is difficult to select those with renal insufficiency from among evaluable BPH patients.e. Cook TJ. It was also shown that neither the symptom score nor the quality-of-life assessment was associated with serum creatinine levels in patients with BPH. Storage (irritative) and voiding (obstructive) symptoms as predictors of benign prostatic hyperplasia progression and related it is probably unwise to avoid measuring serum creatinine levels in patients undergoing BPH evaluation in an effort to minimize costs.3.ncbi. it is probably cost effective to measure serum creatinine levels in all patients. Cook TJ. Ten years ago.298:156-159.58:210-216. Quezada WA. it was shown that patients with BPH and renal insufficiency had a 25% risk of developing post-operative complications compared with the 17% risk in patients with normal renal function (2). Narayan P. A recent study evaluated 246 men presenting with BPH symptoms and found that approximately one in 10 (11%) had renal insufficiency (7). Waldstreicher dopt=Abstract Meigs JB. Peters PC. diabetes and hypertension were the most probable causes of the elevated creatinine level among this group of patients. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=2466506& dopt=Abstract Mebust WK.nlm. Aparicio SA. those with severe symptoms and with urinary retention).141:243-247. Malice MP. Holtgrewe HL.15. Koch et al.nlm. Clinical predictors of spontaneous acute urinary retention in men with LUTS and clinical BPH: A comprehensive analysis of the pooled placebo groups of several large clinical trials. Proscar Long-term Efficacy and Safety Study.ncbi.54:935-944.nih. J Urol 1989.ncbi. J Clin Epidemiol 2001. Davison AM. Earlier studies also showed a much higher mortality among BPH patients who underwent surgical treatment when renal insufficiency was present at the same time (3. Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men. Comiter et al. Johnson-Levonas AO.nih.885 patients. Most studies have found that the incidence of azotaemia in men with BPH varies from 15-30% (5. http://www. Barry MJ.4). we feel that this study does not address this issue. 3. In the report from the AHCPR (11) and in the recommendations of the Fourth International Consultation on BPH (12). McKinlay JB. This point is increasingly emphasized. Transurethral prostatectomy: immediate and postoperative complications.nlm. (8) reported a study in which voiding dysfunction of a non-neurogenic aetiology did not appear to be a risk factor for elevated BUN (blood urea/nitrogen) and creatinine levels. 17. Mohr B. Eur Urol 2002. Collins MM. Although the recently released MTOP’s data suggest that creatinine measurements might not be indicated. Urology 2001. Roehrborn CG. Br Med J Bevan A. http://www. Despite all of the above. When renal dysfunction was present.nlm. Saltzman B. This study also noted that it was rather rare to find patients with high creatinine levels due to bladder outlet obstruction only.6).

ncbi. Reda DJ. Quick Reference Guide for Clinicians. it enhances the capacity to estimate prostate volume. Karrison TG. 1998. Nissenkorn I. Serum creatinine measurement in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia.87:450-459. Initial diagnostic evaluation of men with lower urinary tract symptoms. but also frequently in men with urinary tract infections. US Department of Health and Human Services: Rockville. Griffiths K. Foret JD. 3. Plymouth: Health Publications.49:697-702. However. Schacterle RS.ncbi. and in this way may assist in choosing the right treatment. Proceedings of the Fourth International Consultation on BPH. Boner The outcome of renal ultrasound in the assessment of 556 consecutive patients with benign prostatic hyperplasia. Scientific Communication International Jersey.fcgi?cmd=Retrieve&db=PubMed&list_uids=4424347& dopt=Abstract Roehrborn CG. 7.ncbi. Urodynamic risk factors for renal dysfunction in men with obstructive and non-obstructive voiding dysfunction.nih. as prostate size has been shown 16 UPDATE MARCH 2004 .4 Urinalysis Since LUTS is not only observed in patients with BPH.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490828& dopt=Abstract McConnell JD. J Urol 1962. http://www.nlm.nlm. Proceedings of the Third International Consultation on Benign Prostatic Hyperplasia (BPH). Artibani W. This is mainly due to the low specificity of this highly sensitive test. Geneva.nlm.. such as malignancies.nih.1 RECOMMENDATION Urinalysis is recommended in the primary evaluation. de la Rosette JJ. J Urol 1995. Khoury S et al. 5. analytical and microscopic urine analysis was considered to be mandatory.nih. J Urol 1997. Phelan M. Firstly.fcgi?cmd=Retrieve&db=PubMed&list_uids=89133& dopt=Abstract Gerber GS. 9.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186351& dopt=Abstract Bruskewitz RC.fcgi?cmd=Retrieve&db=PubMed&list_uids=9145973& dopt=Abstract Comiter GV. Valk WL. Wasson JH.htm#bphimp Koyanagi MD. 179-265. eds. Cohen LH. 4. microscopic urine analysis has not been accepted as a screening test for the early detection of severe urological diseases. http://www.nih.4. Bruskewitz RC. Correa R et al..112:643-646. it should be noted that there is little evidence in the literature to support this conclusion. Occult progressive renal damage in the elderly male due to benign prostatic hypertrophy.ncbi. Mebust WK.plymbridge. Valla SV. AHCPR publication 94-0583. Testing to predict outcome after transurethral resection of the prostate. pp. J Urol 1997.ncbi. whether related or not to benign enlargement of the gland. Channel Islands. pp. 167-254.fcgi?cmd=Retrieve&db=PubMed&list_uids=9120927& dopt=Abstract Koch WF. February 1994. http://www. In: Cockett AT et al. Agency for Health Care Policy and Research.158:181-185. Mukamel E. http://www. http://www. http://www.5 Digital rectal examination (DRE) Digital rectal examination (DRE) is an important examination in men with LUTS for two reasons. causing unnecessary further diagnostic measures in a large number of patients. we concluded that this inexpensive test which does not require sophisticated technical equipment should be incorporated in the primary evaluation of any patient presenting with Barrett L. In: Denis L.ahrq.fcgi?cmd=Retrieve&db=PubMed&list_uids=13908592& dopt=Abstract Melchior J. de Wildt MJ. Valk WL.27:403-406. Barry MJ. http://www. Public Health Service.ncbi. 11. J Urol 1974.ncbi. 6. it can help to determine the co-existence of prostatic carcinoma. Urology 1997.nlm. and in at least 25% of patients with carcinoma of the bladder. Paris. Holtgrewe HL.nlm.nih. Goldfisher ER.3.157:1304-1308. 1996. 8. Factors influencing the mortality and morbidity of transurethral prostatectomy: a study of 2015 cases. Transurethral prostatectomy in the azotemic patient. Sullivan MP. Overall.nlm.nih. Bales GT. Ezz El Din K. July 1997. Secondly. Debruyne FM. Benign Prostatic Hyperplasia: Diagnosis and Treatment. 155:186-189. http://www. J Am Geriatr Soc 3. Servadio C. 12. 10. 3.

DRE had a significant influence on the likelihood of a positive biopsy in all PSA and age ranges (2). and embarrassment (12). Frand I. UPDATE MARCH 2004 17 .com/ Potter SR.ncbi.nlm. 3. DRE is useful in evaluating the size of the prostate gland and also in order to exclude other pelvic pathologies. Colorectal and Ovarian (PLCO) screening trial and in the European Randomized study of Screening for Prostate Cancer in Europe (ERSPC). Candas B.051 men. Suburu RE. CONCLUSIONS AND RECOMMENDATION DRE has been used in all major screening trials but its actual impact in the early diagnosis of PCa has been questioned. depends on the actual prostate volume.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377318& dopt=Abstract Labrie F.4.nih. prostate-specific antigen. an estimation of the prostate gland volume will help the urologist to select the most suitable form of treatment with the lowest cost and best outcome. McConnell J eds. used three clinical parameters. For this reason. 3. These figures are based on screening studies and it is believed that DRE will have a higher PPV for cancer among men with LUTS. have compared the knee-elbow to the left-lateral position of the patient in examining and evaluating the prostate.57:1100-1104.21) (7). Ackerman be a determining factor for certain treatment options.nih. such as surgery. Frank et al. PSA and DRE. 3. Cidre J.. is recommended. Lung. In patients for whom invasive therapy. Bartsch G. Denis L. Similar models to assist training for DRE examinations have been proposed by other groups as well (11). In this study. In the “Quebec” (3). Foo S. Response to certain types of therapy. Foo K.1 DRE and cancer detection The positive predictive value (PPV) of a suspicious DRE to actually diagnose prostate cancer is 26-34% (1). Roehrborn developed a model of visual aids to help urologists predict prostate volume more accurately (10). DRE has been used as an ancillary screening tool. They concluded that both methods were equal in completeness of examination. In the European Prostate Cancer Detection Study (EPCDS) of 1.5. Plymbridge Distributions. DRE has been used in the screening process. but proper training is needed. Correct estimation of the prostatic volume by DRE is not an easy task and therefore investigators for the PLCO (Prostate. Khoury S. Although different methods and criteria were used in the four studies. http://www. Screening decreases prostate cancer death: first analysis of the 1988 Quebec prospective randomized controlled trial. Gomez Lung. In the Prostate. was abandoned (6).5. Recommendation: DRE is recommended in the evaluation of men with LUTS. the “Innsbruck”(4) and the “Olmsted County”(5) screening trials. 3.ncbi. Roehrborn has analyzed the data from four studies in which estimations of prostate volume by DRE were compared with those performed by TRUS (9). Diamond P. pain. Prostate 1999. to determine the probability of having prostate cancer and constructed a nomogram to help in the decision whether or not to perform a prostate biopsy. Levesque J. e. Benign prostatic hyperplasia. age. Urology 2001.3 2. particularly if the volume was greater than 30 mL. DRE results were not a significant predictor of prostate cancer (P=0.fcgi?cmd=Retrieve&db=PubMed&list_uids=9973093& dopt=Abstract 2.plymbridge. http://www. In: Chatelain C. and digital rectal examination as determinants of the probability of having prostate cancer. as these patients are usually older. 1. 2000.5.5. Partin AW. Tinzl M. http://www. Fifth International Consultation on BPH. 3.2 DRE and prostate size evaluation A number of options are currently available for the treatment of patients with BPH. In 1997 the use of DRE in the ERSPC trial as a screening test. finasteride. 169-188. Potter et al. Colorectal and Ovarian Cancer) trial have described quality-control procedures for DRE examination (8). Dupont A.nlm. Cusan L.38:83-91. Age. it was concluded that underestimation of DRE increased with increasing TRUS volume. pp. It is well-accepted that TRUS is more accurate in determining prostate volume than DRE. Bosch J. Finally. REFERENCES Resnick M. Horniger W. Belanger A.

http://www. and an update on incidence trends in Olmsted County. Quality control of cancer screening examination procedures in the Prostate. 7. Decline in prostate cancer mortality from 1980 to 1997.nih. http://www.87:331-333. Urology 1998. and that 16 of 24 centres (67%) used plain films as routine procedures prior to prostatectomy (14). Taylor R. the role of routine imaging of the upper and lower urinary tract in all patients with LUTS has been increasingly questioned in recent years (5.161:529-533. Prostate cancer mortality after introduction of prostate-specific antigen. http://www. Boyle P.ncbi. Emberton M. Sech S. Control Clin Trials 2000. J Urol 1999. Tyrol Prostate Cancer Screening Group.fcgi?cmd=Retrieve&db=PubMed&list_uids=10513131& dopt=Abstract Frank J. has been an integral part of the diagnostic assessment of elderly men with LUTS due to BPH during past decades (1-12).nih. 12. mass screening in the Federal State of Tyrol. http://www. Bartsch G. The most common argument in favour of routine imaging of the upper urinary tract was ‘not to miss anything’.4.30:239-251.ncbi.nih.nih. dopt=Abstract 3.fcgi?cmd=Retrieve&db=PubMed&list_uids=9915441& dopt=Abstract Schröder FH. In parallel with endoscopy. Lieber MM. Similar findings. Couch or crouch? Examining the prostate.ncbi.nih. 10. IEEE Trans Biomed Eng 1999.nlm. Thomas K. Data from several large-scale studies have led to doubts concerning the role of routine upper urinary tract imaging in patients with LUTS.46:1253-1260. Montoya J.nlm.Screening for prostate Colorectal and Ovarian (PLCO) Cancer Screening Trial. 58:417-424. Urol Clin N Am 2003. Girman CJ.nih. Andrews S. Urology 2001. Interexaminer reliability and validity of a three-dimensional model to assess prostate volume by digital rectal Schulman CC.nlm.57:1087-1092. Bergstaralh EJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=9586592& dopt=Abstract Roehrborn CG. Basharkhah A.9. Austria.6 Imaging of the urinary tract Imaging of the entire (including the upper) urinary tract. Oliver S. 3. O’Brien B. Lung. Robertson C. Minnesota.nlm. http://www.6. 9.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=11549491& dopt=Abstract Roberts RO. Reissigl A.051 men. J Urol 2000. Urology 2001. Choong S. 11. a randomized study comparing the knee-elbow and the left-lateral position. Horninger W. Colorectal and Ovarian Cancer Screening Trial Project Weiss RE. Zlotta AR.ncbi. Remzi M. http://www.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=12735501& dopt=Abstract Djavan B.163:1144-1148.nih. Klocker H. BJU Int 2001. have been reported in the USA (15). Patounakis G. Katusic SK.nlm. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11189690& dopt=Abstract Roehrborn CG. Jacobsen SJ. Ghawidel K.ncbi.1 Upper urinary tract A recent survey of 24 urological centres in the UK found that 21 of 24 centres (79%) used either intravenous urography (IVU) or sonography. Virtual reality-based training for the diagnosis of prostate cancer. Oberaigner W. Schonitzer D.51(Suppl 4A):19-22. Fagerstrom RM.nlm. Prostate. particularly a high rate of IVU. Marberger M. Optimal predictors of prostate cancer in repeat prostate biopsy: a prospective study in Popescu V.13). Wilkinson and Wild (12) reported on 175 patients with LUTS with no urinary retention and identified no abnormalities on renal ultrasound and IVU that would have altered the therapeutic 18 UPDATE MARCH 2004 . 21(Suppl 6):S390-399. Severi G.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377314& dopt=Abstract Burdea G.nlm.nlm. an imaging modality for patients with LUTS should provide both imaging of the urinary tract and demonstrate the morphological effects of prostate pathology upon the rest of the lower and/or upper urinary tract. 8. Rhodes T.ncbi. particularly prior to prostate surgery. 6. Accurate determination of prostate size via digital rectal examination and transrectal ultrasound. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=10737484& dopt=Abstract Weissfeld JL.6.nih.

0002. Based on several autopsy and epidemiological studies. respectively.6% of IVU and 6.3% and 0. The average radiation dose is 1.18). Reliable data on inter. (20) concluded that bladder wall thickness appeared to be a useful predictor of bladder outlet obstruction.5% and 15. IVU adverse events A review of 10 reported studies involving over 2. usually seen in about 1% of cases.131 men from nine ultrasound series were involved. Serum creatinine levels appeared to be correlated with dilatation of the renal pelvis.000-200. A recent review was carried out on data from 25 published reports on the findings of IVU. Manieri et al. A total of 6.2 Lower urinary tract Urinary bladder voiding cysto-urethrogram This investigation suffers from the fact that the information on the lower urinary tract is only indirect and gives. and solid renal masses were identified in 0.8%.4 years (16). Among the most important are: • better characterization of renal masses • possibility of investigating the liver and retroperitoneum • simultaneous evaluation of the bladder. 3. 30% had measurable degrees of renal insufficiency. 3. Hydronephrosis was found in 7.1 million patients revealed an incidence of adverse effects due to contrast medium in approximately 6% of patients. 74. Overall. UPDATE MARCH 2004 19 .4 Prostate Imaging of the prostate is performed to assess: • prostate size • prostate shape • occult carcinoma • tissue characterization.6. the measurement of bladder wall thickness by transabdominal ultrasound has gained considerable interest as a non-invasive tool to assess bladder outflow obstruction (19). including 778 patients with LUTS due to BPH. These data need to be correlated with the incidence of renal cell cancer in the general population. More recently. therefore. However. measurement of bladder wall thickness is currently not part of the recommended diagnostic work-up of patients with LUTS. Poor or no renal function was found in 12. 3. It is therefore not recommended in the routine diagnostic work-up of elderly men with LUTS.6. an incidence of serious adverse effects in 1 in 1.58 rem. in patients with pre-existing renal failure. Other malignancies found during routine examination of the urinary tract are bladder and ureteral cancer.000 (17. Low-osmolar contrast material (LOCM) resulted in a six-fold improvement in safety compared with high-osmolar contrast material (18). The mean patient age in these series was 68.approach. post-void residual urine volume and prostate • costs • avoidance of irradiation • no side-effects. These figures are comparable with the results of large-scale studies in elderly men with LUTS and indicate that the incidence of renal carcinoma is not increased in these patients.18% to 0. it has been estimated that the risk of elderly men developing renal cell cancer ranges from 0. The authors concluded that renal ultrasound is only indicated in patients with an elevated serum creatinine level and/or post-void residual urine volume (13).3% of all IVUs and 70% of all the ultrasound studies performed were normal.000.3 Urethra Retrograde urethrography gives only indirect information on the effect of benign prostatic enlargement (BPE) on adjacent structures.. only limited urodynamic information. who performed renal ultrasound scans in a consecutive series of 556 elderly men with LUTS.6. 14 (2. IVU or renal ultrasound Several arguments support the use of renal ultrasound.56%.8% of ultrasonography patients.5%) had hydronephrosis (13). most of the cancers suspected during imaging were not identified during endoscopy. at best. Furthermore.81% and 0. A number of tumours were identified during endoscopy that had been overlooked during imaging. as well as reproducibility. the use of LOCM reduces the risk of nephrotoxicity (18). with a value exceeding that of uroflowmetry. are still lacking and. and a risk of dying from an allergic reaction of 1 in 100.3%. Similar data have been published by Koch et al.and intra-observer variability. Renal cysts were seen in 4.51% of IVU and of ultrasonography patients.

Routine intravenous urograms prior to prostatectomy. The diagnostic value of intravenous pyelography in infravesical obstruction in males. Prostate size A large body of evidence documents the accuracy of TRUS in calculating the volume of the prostate (22.nih. only imaging of the prostate by TRUS. Prostate shape Watanabe (25) introduced the concept of the presumed circle area ratio (PCAR).nlm.ncbi. 6. Bundrick TJ. orthogonal plane.nih. Blandy JP.fcgi?cmd=Retrieve&db=PubMed&list_uids=1131499& dopt=Abstract Morrison JD. Br J Clin Pract 1980. 4.86:171-172.nih.ncbi.ncbi.nih.123:390-391. Jacobsen O. the shape of the prostate is changed by the continuous growth of the transition zone.fcgi?cmd=Retrieve&db=PubMed&list_uids=731806& dopt=Abstract Marshall V. http://www.ncbi. Eur Urol 10. Komaranchat A. In BPE. Kakiailatu F. http://www.ncbi. Urwiller RD. Moller I.fcgi?cmd=Retrieve&db=PubMed&list_uids=74088& dopt=Abstract Bohne AW. REFERENCES Andersen JT. http://www. Singh M. TRUS has significantly higher accuracy than that of cystoscopy. Scand J Urol Nephrol 1977. Standgaard L.ncbi. Johnson S.nih. if this is not available.12:464-466.75 or less than 75. http://www. Prostate volume can be estimated by serial planimetry. J Urol 1961. Donnelly by transabdominal ultrasound.147:957-959.11:225-230. ellipsoid) and three-dimensional methods (23).fcgi?cmd=Retrieve&db=PubMed&list_uids=2451969& dopt=Abstract Donker PJ. Urology 1978.nlm. This is based on the usual normal triangular-shaped appearance of the prostate in the absence of benign prostatic enlargement (BPE).fcgi?cmd=Retrieve&db=PubMed&list_uids=6158963& dopt=Abstract Pinck BD.nlm. and that BPE is very unlikely to be the cause of the post-void residual urine volume.5 1. Help or habit? Excretion urography before prostatectomy.296:965-967.nih.46:73-76.nlm. The prostate volume estimated by DRE and endoscopy is known to underestimate prostates over 40 mL in size (24). 9. Preoperative evaluation of patients with bladder outlet obstruction with particular regard to excretory urography. however. Excretory urography: a superfluous routine examination in patients with prostatic hypertrophy.23).nlm.7:65-67.ncbi.nih. Prostatism: how useful is routine imaging of the urinary tract? Br Med J 1988.fcgi?cmd=Retrieve&db=PubMed&list_uids=6767041& dopt=Abstract 2. http://www.6. is currently used (21). In daily routine practice. More likely causes include bladder cancer or prostate cancer. 20 UPDATE MARCH 2004 . Pre-prostatectomy excretory urography: does it merit the expense? J Urol 1980.fcgi?cmd=Retrieve&db=PubMed&list_uids=2429536& dopt=Abstract Butler MR. J Urol 1978.nlm.nlm. http://www. 8. validation of these data by others is still lacking. rectal examination and or urethral pressure profile (24). 7. Mee D. IVU.fcgi?cmd=Retrieve&db=PubMed&list_uids=715976& dopt=Abstract Christofferson I. http://www. Intravenous urography in evaluation of acute Am J Radiol 1986. Corrigan MJ.nlm. Is urography necessary for patients with acute retention of urine before prostatectomy? Br J Urol 1974. Jasper P. Pantos dopt=Abstract DeLacey G. Watanabe reported that pathological residual urine is seen if the presumed circle area ratio (PCAR) is greater than 0. 3.Choice of imaging modalities The prostate can be imaged using: • transabdominal ultrasound • TRUS • computed tomography (CT) and magnetic resonance imaging (MRI) (including transrectal MRI). rotational body (single plane. http://www. Excretory urography in patients with prostatism. Katz PG. 3.ncbi.

fcgi?cmd=Retrieve&db=PubMed&list_uids=8813917& dopt=Abstract Aarnink RG. Ukimura O. http://www. Debruyne FM. 15. Radiology 1987.nlm. New concept of BPH: PCAR theory.ncbi. Benign prostatic hyperplasia. http://www. http://www. http://www. Debruyne Inui E. Correa R et al. Wasserman NF.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=8489830& dopt=Abstract Kojima M. 155:186-189. Debruyne FM. Peters PC.nih.34:205-209.70:53-57. 20. July 1997.22:321-332. Mebust WK. Paris.ncbi.and low-osmolarity iodinated contrast media. Is pre-operative imaging of the urinary tract worthwhile in the assessment of prostatism? Br J Urol 1992. http://www.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9759706&query_hl=54&itool=pubmed_docsum UPDATE MARCH 2004 21 . Watanabe H.nih. Urol Clin North Am 1995.nlm.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=2643720& dopt=Abstract Koyanagi T. Naya Y. Rosel PR. http://www. Trucchi A. de la Rosette JJ.nlm. http://www. 23. Plymouth: Health Publications. Ezz el Din K.nlm.nih.ncbi. High-osmolar and low-osmolar contrast media. In: Denis Br J Urol 1996. Transurethral prostatectomy: practice aspects of the dominant operation in American urology. Romano G.fcgi?cmd=Retrieve&db=PubMed&list_uids=7539178& dopt=Abstract Aarnink Barrett BJ. pp.165:831-835. 24.nih. Radiology 1993. J Urol 1997. de la Rosette Wijkstra H.157:476-479. Wild SR.51:19-22. Noninvasive quantitative estimation of infravesical obstruction using ultrasonic measurement of bladder weight.159:1568-1579. 21. Wild SR.nih.nlm. Assessment of prostatism: role of intravenous urography. 14. Imaging of the prostate. http://www.37:116-125.fcgi?cmd=Retrieve&db=PubMed&list_uids=8511292& dopt=Abstract Thomson HS.nih. J Urol 1998. Cockett AT. J Urol 1998. Artibani W.141:248-253. Dowd JB.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490828& dopt=Abstract Wilkinson AG. The diagnosis of bladder outlet obstruction in men by ultrasound measurement of bladder wall thickness.fcgi?cmd=Retrieve&db=PubMed&list_uids=9474143& dopt=Abstract Scheckowitz EM. Accurate determination of prostate size via digital rectal examination and transrectal ultrasound. http://www. Ochiai A.nih. 179-265.nlm. Acta Radiol 1993. Meta-analysis of the relative nephrotoxicity of high.159:761-765. Carlisle EJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=9586592& dopt=Abstract Watanabe H.11. Lapointe 13. Dorph S.ncbi.nlm. Urology 1998. Prostate 1998. Khoury S et al.fcgi?cmd=Retrieve&db=PubMed&list_uids=1379104& dopt=Abstract Holtgrewe HL.. http://www.nlm. 22. Wijkstra H. Griffiths Carter SS.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=2446348& dopt=Abstract Wilkinson AG.ncbi. de Wildt The outcome of renal ultrasound in the assessment of 556 consecutive patients with benign prostatic hyperplasia. 19. Transrectal ultrasound of the prostate: innovations and future Resnick MI.plymbridge. J Urol Tubaro A.fcgi?cmd=Retrieve&db=PubMed&list_uids=8996337& dopt=Abstract Manieri C. J Urol 1996. Proceedings of the Fourth International Consultation on BPH.nih.nih.Survey of urological centres and review of current practice in the pre-operative assessment of prostatism. Beerlage HP. http://www. 25. http://www. Br J Urol 1992.fcgi?cmd=Retrieve&db=PubMed&list_uids=1379105& dopt=Abstract Koch WF. Reproducibility of prostate volume measurements from transrectal ultrasonography by an automated and a manual technique. de la Rosette JJ.188:171-178. http://www. 12. http://www.ncbi. Valenti M.fcgi?cmd=Retrieve&db=PubMed&list_uids=9554357& dopt=Abstract Roehrborn CG. Eckmann Proctor C.ncbi.ncbi.

gov/entrez/query.2). one of the causes of nocturia in elderly men (4-6).fcgi?cmd=Retrieve&db=PubMed&list_uids=8908664& dopt=Abstract Reynard JM. Voiding charts allow. It is a simple. 4. 61% for the time of voids and 68% for episodes of nocturia (2).ncbi. Br J Urol Int 1999. such as frequency and nocturia. Bosch JLHR.nlm. 22 UPDATE MARCH 2004 Bohnen AM. http://www. Donavan JL.82:619-623. http://www.ncbi.nlm. Yang Q. Klevmark B. 3.ncbi. Gisholf KWH. Peters TL.7. Analysis and reliability of data from 24-hour frequency-volume charts in men with lower urinary tract symptoms due to benign prostatic hyperplasia.nih. http://www. Groeneveld FPMJ. Men with LUTS and normal Qmax are more likely to have a non-BPH-related cause of their symptoms. REFERENCES Abrams P. non-invasive test that can reveal abnormal voiding. recent data indicate that a 24-hour voiding chart is sufficient and that longer time periods provide only little additional information (3). and data generated by voiding charts. Eur Urol 2000. http://www.38:45-52. for Flow rate machinery provides information on voided volume. Schäfer W. 3. 6. 3.fcgi?cmd=Retrieve&db=PubMed&list_uids=11173938& dopt=Abstract Blanker MH.1 CONCLUSIONS Recording of a 24-hour frequency volume chart in the course of an initial consultation is considered to be a standard investigation. and provides important insights into LUTS. 3. The ICS-BPH study: uroflowmetry.7 Voiding charts (diaries) Voiding charts (diaries) are simple to complete and can provide useful and objective clinical information (1. Mortensen JT. Br J Urol 1998.3.nih. The ICS BPH study reported an exact correlation in 41% of the number of voids. Normal voiding patterns and determinants of increased diurnal and nocturnal voiding frequency in elderly men. Data from frequency-volume charts versus symptom scores and quality of life score in men with lower urinary tract symptoms due to benign prostatic hyperplasia.7.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=10368248& dopt=Abstract 2.8 Uroflowmetry Uroflowmetry is recommended as a diagnostic assessment in the work-up of patients with LUTS and is an obligatory test prior to surgical intervention. Nocturia and polyuria in men referred with lower urinary tract symptoms. However. Eur Urol 2001.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=10992366& dopt=Abstract Matthiesen TB. Scand J Urol Nephrol 1996. Boon TA. There is no standard frequency volume chart available. assessed using a 7-day frequency-volume chart.ncbi. Serial flows (two or more) with a voided volume exceeding 150 mL are recommended to get a representative flow rate. lower urinary tract symptoms and bladder outlet obstruction. and this information should be interpreted by the physician to exclude artifacts (1-3).nih.nlm.164:1201-1205.fcgi?cmd=Retrieve&db=PubMed&list_uids=10859441& dopt=Abstract Van Venrooij GEPM. de la Rosette JJ. Bernsen RMD. Boon TA. Eckhardt MD.nih. Frequency volume charts: an indispensable part of lower urinary tract assessment. men with a Qmax less than 10 mL/sec are more likely to have BOO and are therefore more likely to improve with surgery. Prins A. inexpensive.fcgi?cmd=Retrieve&db=PubMed&list_uids=9839573& dopt=Abstract Gisolf KWH. Rittig S. Lim AT.nlm. http://www.nlm. Osawa D. http://www. as assessed by symptom scores.2 1. Djurhuus JC. A frequency volume chart is non-invasive .gov/entrez/query. van Venrooij GEPM. maximum flow rate (Qmax). average flow (Qave) and time to Qmax. J Urol 2000. the identification of patients with nocturnal polyuria. There is a close correlation between LUTS.10) and flow rates should interpreted with caution in particular as elderly men with LUTS have age-related urodynamic changes (4).nlm. BOO can only be diagnosed with a pressure flow study (pQs) (see section 3.ncbi. Eckhardt MD.83:1017-1022. Abrams P.nih. Dabhoiewala NF.

nlm. Patients with low-pressure and low-flow urodynamics may also have a successful outcome following prostatectomy. James ED.nih. Those developed by Schafer (8). http://www. In specific patient subgroups. Studies reported by Neal et al.149:339-341.8.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8863566&query_hl=83&itool=pubmed_docsum 2. 3. residual urine is not a contraindication to watchful waiting or medical therapy. but the probability is lower.ncbi. Abrams et al. debate continues as to their role in predicting treatment outcomes. Geffriaud C. Detrusor pressure at the point of maximum flow must be recorded in order to diagnose obstruction.1 1. Maximum urinary flow rate by uroflowmetry: automatic or visual interpretation. Klingler HC.ncbi. Schmidbauer CP. Wijkstra H. it is known that patients with high-pressure and low-flow urodynamics have the best outcome from prostatectomy. http://www. such as in elderly patients.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9471041&query_hl=80&itool=pubmed_docsum Madersbacher S. they remain optional. accurate and non-invasive method. and because pressure-flow studies are regarded as invasive. UPDATE MARCH 2004 23 . Large PVR volumes (> 200-300 mL) may indicate bladder dysfunction and predict a less favourable response to treatment. width. The methodology for performing pressure-flow studies is now standardized (7) and requires simultaneous recording of both intravesical and intra-abdominal pressure. Stulnig T. REFERENCES Rowan D. Jensen (15). Abrams and Griffiths (9) and Rollema and Van Mastrigt (URA – Urethral Resistance Index) (10) are most commonly used. Urodynamic equipment: Technical aspects. the case for pressure-flow studies is stronger. Although pressure-flow studies are the only means of diagnosing obstruction accurately. 3. whereas pressure-flow studies can categorize the degree of obstruction and identify patients in whom a low flow rate may be due to a low-pressure detrusor contraction. However. J Urol 1996. (14). Sterling AM.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2956425&query_hl=67&itool=pubmed_docsum Grino PB. Different nomograms exist with which to classify patients into categories of obstruction. Bruskewitz R.156:1662-1667. (17) all report improved outcomes in patients who are obstructed prior to surgery.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7678870&query_hl=71&itool=pubmed_docsum Witjes WP. For this reason. http://www. Andersen JT.und inter-individual observer accuracy in interpretation of pressure-flow curves have demonstrated a considerable methodological variation (3-6). It should be calculated by measurement of the bladder height.1 Outcome Pressure-flow studies do not predict the response to medical therapy and have no role in this setting.33:54-63. Suhel PF. de la Rosette JJ. (16) and Langen et al. 3.nlm. Flow rates may be particularly limited in predicting obstruction in specific situations. Vignoli GC. and should be used in clinical practice. Debruyne FMJ.nlm.10 Urodynamic studies Pressure-flow studies are regarded as an additional diagnostic test and are considered optional by both the AUA guideline panel on management of benign prostatic hyperplasia (2003) (1) and the Fifth International Consultation on BPH (2). it is not possible to establish a PVR “cut-point” for treatment decision. based on pressure-flow studies.13).ncbi.nih. The ICS (International Continence Society) nomogram (11) has now been adopted as the standard nomogram to aid comparison of different data or men with a Qmax of more than 10mL/s. Still.9 Post-void residual volume Post-void residual (PVR) urine measurement is recommended during initial assessment. Robertson et al. J Med Eng Technol individuals with low voided volumes. Schatzl G.10.nih. Flow rates only determine the probability of obstruction. This makes it more difficult to judge the influence of infravesical obstruction on lower urinary tract symptoms in patients with BPH. 3. Siroky MB. Kramer AE. Age-related urodynamic changes in patients with benign prostatic hyperplasia. Eur Urol 1998. Recent methodological studies looking on intra-individual variation in pressure-flow results as well as intra. and length obtained by transabdominal ultrasonography. Blaivas JG. Marberger M. Most work in relation to pressure-flow studies and treatment of LUTS due to BPO relates to TURP. Because of large test-retest variability and lack of outcome Cook T.ncbi. Stoner E. (12. This is a simple. http://www. Zerbib M. and they all correlate closely. Computerized artefact detection and correction of uroflow curves: Towards a more consistent quantitative assessment of maximum flow.nih.3. J Urol 1993. as well as in the presence of neurological disease.11:57-64.

Styles RA. Kallestrup E.51:129-134. http://www. 4. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11071695& dopt=Abstract Eri LM.fcgi?cmd=Retrieve&db=PubMed&list_uids=2956425& dopt=Abstract Schafer W. Test-retest variation of pressure flow parameters in men with bladder outlet obstruction. 13.fcgi?cmd=Retrieve&db=PubMed&list_uids=10797579& dopt=Abstract Rowan D. J Med Eng Technol 1987. McConnell J eds.nih.nih. July 2000. Powell PH.fcgi?cmd=Retrieve&db=PubMed&list_uids=465971& dopt=Abstract Rollema HJ. Standardization of terminology of lower urinary tract function: pressure-flow studies of voiding.nlm. http://www.3 REFERENCES 1.148:111-115. J Urol 1993. Atan A. The ICS nomogram should be used for the diagnosis of obstruction in order to standardize data for comparative purposes. International Continence Society Subcommittee on Standardization of Terminology of Pressure-Flow Studies. Improved indication and follow-up in transurethral resection of the prostate using the computer program CLIM: a prospective study. A new concept for simple but specific grading of bladder outflow condition independent from detrusor function. Neurourol Urodyn 1999. J Urol 1992.165:1188-1192. 10.nlm. 3. Neurourol Urodyn These studies are the most useful investigations available for the purpose of counselling patients regarding the outcome of surgical therapies for BPH. Smith A.nlm. http://www.nih. Paris. Neurourol Urodyn 2000. Webb RJ. 5.10. Wijkstra H. 6. James ED.ncbi.ncbi.149:574-577.nlm. Denis L. van Mastrigt R. 2001. urethral resistance and urethral obstruction. Nordling J. The assessment of prostatic obstruction from urodynamic measurements and from residual urine.nlm.ncbi. 7. Plymouth: Health Intra. http://www. Spangberg A. Olsen L. J Urol Hansen F. Wessel N. Br J Urol 1987. Powell PH. BMJ 1989.16:1-18. http://www.and Inter-investigator variation in the analysis of pressure-flow studies in men with lower urinary tract symptoms. Kramer AE. Abrams P. symptoms and urodynamic findings in 253 men undergoing prostatectomy.18:205-214. Berge V.fcgi?cmd=Retrieve&db=PubMed&list_uids=9021786& dopt=Abstract Neal DE.ncbi. Pressure-flow studies: Short term repeatability.ncbi. Suhel PF.nih. Griffiths dopt=Abstract Griffiths D. Foo KT. http://www.ncbi. Sharples L. Urodynamic equipment: technical 524. AUA guidelines on management of benign prostatic hyperplasia (2003). http://www.plymbridge. Ramsden PD.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=3427341& dopt=Abstract Neal DE.nih. Chapter 1: Diagnosis and treatment Nordling J. J Urol 2001.ncbi. Proceedings of the Fifth International Consultation on BPH. Kiemeney LA. Verbeek AL.19:637-651. Br J Urol 1979.ncbi. http://www. Ramsden PD. Khoury S. Sonke GS.nlm. Hofner K. Rollema HJ.2 CONCLUSIONS Pressure-flow studies remain optional tests in straightforward cases presenting for the first time with LUTS. Neurourol Urodyn 2000. Thong J. Styles RA. Relationship between voiding pressure. de La Rossette JJ. Gleason D. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11257668& dopt=Abstract Kortmann BB. Sterling AM. 24 UPDATE MARCH 2004 .gov/entrez/query.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=2508914& dopt=Abstract 2. 8. Kortmann BB.170:530-547. de La Rosette JJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=12853821& dopt=Abstract Chatelain C.nlm. Produced by the International Continence Society Working Party on Urodynamic Equipment. AUA practice guideline committee.nih.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=10338441& dopt=Abstract Sonke GS. 3. van Mastrigt R.nlm. Outcome of elective prostatectomy. http://www. http://www.nlm.11:57-64. Holm NR.nlm. Debruyne F.nih. Variability of pressure-flow studies in men with lower urinary tract symptoms.

UPDATE MARCH 2004 25 . indicating the presence of such obstruction. Griffiths C. Urodynamic assessment in patients undergoing transurethral resection of the prostate: a prospective study.11 Endoscopy The standard endoscopic procedure for diagnostic evaluation of the lower urinary tract (urethra. 75-84.nlm. However. http://www.155:506-511.11. This obstruction has a critical role in altering voiding. 3. In: Jakse Clinical evaluation of routine urodynamic investigations in prostatism. Thus. Benign Prostatic Hyperplasia: Conservative and Operative Management.fcgi?cmd=Retrieve&db=PubMed&list_uids=8558647& dopt=Abstract Langen PH. The pre-operative peak flow rate was normal in 25% of 60 patients who had no bladder trabeculation. Whiteside CG. bladder neck and bladder) is a urethrocystoscopy.11. Neal DE. Robertson AS. while moderate-to-severe trabeculation was predictive of larger prostate size and reduced flow rate (8). resulting in significant (pathological) changes in the urinary tract of some patients and symptoms alone in others. 1992. The results of prostatectomy: a symptomatic and urodynamic analysis of 152 patients. et al. prostatic occlusion of the urethra and estimated prostate size (3). There appeared to be a trend towards lower peak flow rates in men with higher degrees of trabeculation.5).nlm. it was noted that trabeculation significantly increased with increasing age (p < 0. 15. 3. Neurourol Urodynam 1989. J Urol 1996. BPH may be associated with a relatively small prostate and marked obstructive symptoms if the obstructing tissue originates exclusively within the central zone of the peri-urethral gland area (2).ncbi. New York: Springer-Verlag. (5) evaluated 122 patients of mean age 64 years with LUTS using three post-operative uroflowmetry tests and symptom evaluation. Hyperplasia may be associated with striking lateral lobe enlargement. Conventional urodynamics and ambulatory monitoring in the definition and management of bladder outflow obstruction. 3. Patients with BPH or other forms of bladder outlet obstruction may develop certain signs seen by urethrocystoscopy. http://www. 3.5) between the degree of trabeculation. prostate.4% after urethral instrumentation alone. Conversely. and the peak pre-operative flow rate in 39 men aged 53-83 years with LUTS. In another study. Anikwe (6) showed that there was no significant correlation (p > 0. Turner-Warwick RT..11.1 LUTS caused by bladder outlet obstruction Voiding complaints in elderly men are most frequently caused by BPH resulting in benign prostatic obstruction. Farrar DJ.14. (7) found a correlation between the presence of trabeculation and the number of obstructive symptoms.4 Relationship between trabeculation and symptoms Simonsen et al. the role of BPH in the voiding dysfunction experienced by elderly men is often unclear (1).121:640-642. (4) studied 85 patients and found that the risk of acquiring clinically significant urinary tract infection was 2. as graded from I to IV.8:545-578. indicated by the presence of muscular trabeculation and the formation of cellules as well as diverticula • formation of bladder stones • retention of (post-void residual) urine. It is generally accepted that therapies aimed at removing obstruction will relieve LUTS in most 16. size and severity of obstruction. Several studies have addressed these issues. eds.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=86617& dopt=Abstract Jensen KM-E. When patients were grouped by age. patency of the bladder neck.11. 3. none of the trabeculation ratings were predictive of symptom severity. This investigation can confirm causes of outflow obstruction while eliminating intravesical abnormalities. Abrams PH. Jakse G. pp. 17. urethrocystoscopy may provide information about the cause. J Urol 1979. Schafer W. but symptoms may be negligible if the degree of obstruction is not severe. 21% of 73 patients with mild trabeculation and 12% of 40 patients with marked trabeculation on cystoscopy. These signs may include: • enlargement of the prostate gland with visual obstruction of the urethra and the bladder neck • obstruction of the bladder neck by a high posterior lip of the bladder neck • muscular hypertrophy of the detrusor muscle. All 21 patients who presented with diverticula had an 'obstructive' peak flow rate prior to surgery. Urethrocystoscopy was also performed in these patients. Feneley RC.3 Relationship between trabeculation and peak flow rate Shoukry et al.2 Morbidity of urethrocystoscopy Berge et al.

Instead.003). suggesting the inadvisability of drawing the same conclusion in all patients. While the cystoscopically estimated weight correlated with the presence of trabeculation (p = 0. or more sensitive. increasing amounts of residual urine and bladder instability. the bladder neck to verumontanum distance and the cystoscopic appearance of occlusion did not correlate significantly (p > 0. detrusor instability and low compliance. However. Quirinia and Hoffmann (12) reported on 104 patients with BPH of whom 51% had diverticula by cystography. the majority of all bladder stones are rather small. without carrying the risks of invasive urethrocystoscopy. while approximately 8% of patients have no obstruction at all even if severe trabeculation is present.11. No data are available to document the sensitivity or specificity of cystography.6 Relationship between trabeculation and obstruction El Din et al. (10) showed that patients had a high likelihood of outlet obstruction when their prostate size was greater than 30 mL or if their posterior urethra was severely obstructed on endoscopy. It was concluded that haematuria is a frequent finding in the assessment of BPH patients and that additional tests should only be performed if indicated (e. They believe that the value of urethrocystoscopy is limited and advise against its use in the diagnosis of bladder outlet obstruction. urinalysis and a cystoscopy were performed in 750 consecutive patients with BPH. Only three patients had a bladder tumour while 49 had urinary calculi. however. At present. intravenous pyelography (IVP) or transabdominal sonography.11. Equally poorly documented is the impact that the presence or absence of bladder diverticula might have on outcome after prostate surgery. 26 UPDATE MARCH 2004 . anatomical or neurogenic nature.5). cystoscopy or transabdominal sonography for evaluating large bladder diverticula. In a study by Ezz El Din et al. They noted a clear correlation between cystoscopic appearance (grade of trabeculation and grade of urethral obstruction) and urodynamic indices. such as cystography. It is therefore questionable whether or not urethrocystoscopy should be performed to assess the presence or absence of bladder stones prior to surgery for BPH. evident that other diagnostic modalities. the presence of a large bladder diverticulum might dictate the type of intervention. peak flow rate or prostate size. Homma et al. 3. at detecting large bladder diverticula. that bladder outlet obstruction is present in approximately 15% of patients with normal cystoscopic findings. 3. 3. 3.5 Relationship between trabeculation and prostate size Anderson and Nordling (9) examined the correlation between cystoscopic findings and the presence of trabeculation. IVP. no final decision about the value of cystoscopy in the assessment of bladder diverticula can be made. There was no correlation between any clinical parameter and the finding of microscopic haematuria. For example. However. or by destroying them with endoscopic instruments prior to washing them out. (13). and can be removed during TURP through the sheath of the resectoscope.g. Although the presence of diverticula was related to age.3. It is. It is obvious that the presence of a large bladder stone should guide the surgeon towards an open procedure rather than a lengthy electrohydraulic lithotripsy. there is also no doubt that bladder stones are detected equally well by IVP or by the non-invasive method of transabdominal sonography. Bladder stones are a clear indicator of bladder outlet obstruction. the presence of stones in the bladder indicates an abnormality in the bladder-emptying mechanism and is usually preceded by the presence of residual urine or recurrent urinary tract infections. In fact.11. The crux of the matter has to be whether or not the detection of bladder stones dictates the surgical procedure of choice. stones composed of poorly radio-opaque or radiolucent material are seen very well by transabdominal sonography. particularly as most patients with bladder stones will have microscopic haematuria that will have been detected during the standard basic evaluation.8 Bladder stones and obstruction There is no doubt that the presence of bladder stones can be assessed accurately by urethrocystoscopy. in the case of abnormal urine cytology). it should be used primarily to exclude bladder pathology and to decide between interventional approaches. It should be noted. however.7 Bladder diverticula and obstruction The detection of large bladder diverticula might be of therapeutic importance. (11) evaluated urethroscopic findings and the results of urodynamic studies in 492 elderly men with LUTS. upper tract dilation. there was no relationship with bladder capacity.9 Intravesical pathology The detection of other pathology (urethral or intravesical) is advantageous and can be accomplished by endoscopy better than with most other modalities.11. while being missed on a renal ultrasound. While it is not always clear whether the obstruction is of an organic.11. are equally sensitive.

nlm.15:355-358. 12.fcgi?cmd=Retrieve&db=PubMed&list_uids=9535603& dopt=Abstract El Din KE. Yamaguchi T.nih. Dorflinger T. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=7693606& dopt=Abstract 2. Kirby R et al. 6.nlm.nlm. Takei M. 11. http://www.10 CONCLUSIONS Diagnostic endoscopy of the lower urinary tract should be considered an optional test for the following reasons: • the outcomes of the intervention are unknown • the benefits do not outweigh the harm of the invasive study • patients' preferences are expected to be divided. The scope of the urodynamic examinations and prostate biopsies in patients with benign prostatic hyperplasia. 10. Siroky B eds. Norgaard JP. http://www. Rosier PF.11 REFERENCES 1. 91-104. Jorgensen HS. Susset JG. Gotoh M.nlm.70(Suppl 1): 275-279. Pathology of benign prostatic hyperplasia.172:95-98. J Urol 1996. McConnell JD. 9.ncbi. The correlation between urodynamic and cystoscopic findings in elderly men with voiding complaints. II. http://www. http://www.ncbi.47:559-566. cystometric and urodynamic findings. 4. Int Urol Nephrol pp. The significance of age on symptoms and urodynamic and cystoscopic findings in benign prostatic hypertrophy. Int Surg dopt=Abstract Quirinia A. 5. Scand J Urol Nephrol 1980. J Urol 1993.fcgi?cmd=Retrieve&db=PubMed&list_uids=2448939& dopt=Abstract Barry MJ.25:243-247. Moller-Madsen B.nih.3.ncbi.14:23-27. http://www. Urodynamic evaluation of male outflow obstruction.nih. http://www. Holtgrewe HL. Kawabe K. Scand J Urol Nephrol Suppl 1995. Complications of invasive. eds.fcgi?cmd=Retrieve&db=PubMed&list_uids=7686980& dopt=Abstract Andersen JT. Int J Urol 1998. Cancer 1992. 3. Correlations between clinical findings and urinary flow rate in benign prostatic hypertrophy. 8. Nordling J. http://www.11. Eri LM. Predictability of conventional tests for the assessment of bladder outlet obstruction in benign prostatic http://www. de Wildt MJ. Berge V. 7. Bruskewitz RC. Winfield HN. The correlation between cysto-urethroscopic.ncbi. Dutartre D. Sihelnik SA.ncbi. Clinical Neurourol 1991. Debruyne FM.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=7375838& dopt=Abstract Homma Y.fcgi?cmd=Retrieve&db=PubMed&list_uids=61184& dopt=Abstract Simonsen Elhilali MM. Urol Res 1987.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=1376196& dopt=Abstract Bostwick DG. UPDATE MARCH 2004 27 .fcgi?cmd=Retrieve&db=PubMed&list_uids=1191927& dopt=Abstract Anikwe RM. Lundhus E. Cockett Krane RJ.155:1018-1022. Bladder diverticula in patients with prostatism. Role of uroflowmetry in the assessment of lower urinary tract obstruction in adult males.nlm. Prostatism. 3. Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia.150:351-358. Oxford: Isis Medical Media. In: Textbook of Benign Prostatic Hyperplasia. Grayhack Hoffmann AL. http://www. Tveter KJ.427-443.11.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=8578262& dopt=Abstract Shoukry Larsen EH. de la Rosette JJ. Br J Urol 1975. Wijkstra H.isismedical. Benign prostatic hyperplasia.

gov/entrez/query. 14. de la Rosette JJ. Pressure-flow studies should be considered for patients prior to surgical treatment in the following subgroups: • younger men (e. 15.fcgi?cmd=Retrieve&db=PubMed&list_uids=8977059& dopt=Abstract 3. particularly in elderly men. Measurement of residual urine volume is a recommended test in the assessment of patients with LUTS suggestive of benign prostatic obstruction.13. the use of I-PSS is recommended because of its worldwide distribution and use. 16. Eur Urol 1996. Prostate size should be assessed when considering open prostatectomy and TUIP.nlm. 12. 10. Routine imaging of the urethra is not recommended in the diagnostic work-up of patients with LUTS.30:409-413. DRE is a minimal requirement in patients undergoing investigation for LUTS.e.g. 11. and prior to finasteride therapy. Imaging of the upper urinary tract is recommended in patients with LUTS and one of the following: • History of. In patients undergoing investigation for LUTS. or a current. 3. If the voided volume is less than 150 mL or Qmax is greater than 10 mL/s. Koch WF.12 1. 5.nih. Post-void residual urine measurement is recommended during initial assessment.ncbi. Ezz el Din K. 6. However. 28 UPDATE MARCH 2004 . 7. There is a consensus that if imaging of the upper urinary tract is performed. However. Routine imaging of the urinary bladder cannot be recommended as a diagnostic test in the work-up of patients with LUTS. pressure-flow studies should be considered before surgical intervention. the minimal requirement is to assess the upper urinary tract function with a creatinine measurement and/or an ultrasonographic examination. de Wildt MJ. http://www. it should be noted that there is little evidence in the literature to support this conclusion. 8. Uroflowmetry is recommended as a diagnostic assessment in the work-up of patients with LUTS and is an obligatory test prior to surgical intervention. CT and MRI currently have no place in the routine imaging of the upper urinary tract in elderly men with LUTS. Urinalysis may be included in the primary evaluation. which may have an impact on the treatment modality chosen. urinary tract infection • History of urolithiasis • History of urinary tract surgery • History of urothelial tumour (including IVU) • Haematuria (including IVU) • Urinary retention. 2. < 50 years of age) • elderly patients (i. The predictive value of microscopic haematuria in patients with lower urinary tract symptoms and benign prostatic hyperplasia. 4. The method of choice for the determination of prostate volume is ultrasonography. > 80 years of age) • post-void residual urine volume over 300 mL • Qmax more than 15 mL/s • suspicion of neurogenic bladder dysfunction • after radical pelvic surgery • previous unsuccessful invasive treatment. Ultrasound of the bladder. however. imaging of the prostate by transabdominal ultrasound and TRUS is optional. 9. ultrasonography is the method of choice. Endoscopy is recommended as a guideline at the time of surgical treatment to rule out other pathology and to assess the shape and size of the prostate. is a valuable diagnostic tool for the detection of bladder diverticula or bladder stones. 13. RECOMMENDATIONS FOR ASSESSMENT Among all the different urinary symptom score systems currently available. In straightforward cases presenting for the first time with LUTS. preferably via the transrectal route. pressure-flow studies remain optional tests. Debruyne FM.

Lifestyle advice should include: • reduction of fluid intake at specific times aimed at reducing urinary frequency when most inconvenient. perineal pressure and mental ‘tricks’ to take the mind off the bladder and toilet in the control of irritative symptoms. • use of relaxed and double-voiding techniques. Anxiety regarding prostate cancer can be the principal reason why a man consults his doctor about his urinary symptoms. In many men it is regarded as the first tier in the therapeutic cascade and therefore the majority of men will be offered watchful waiting at some point.2 Education. Reassurance that serious complications are unlikely to occur.a policy of care that has been called watchful waiting (WW). breathing exercises. 4. A large study comparing WW and TURP in men with moderate symptoms showed that those who had surgery had improved bladder function over the WW group (flow rates and post void residual volumes) with the best results being in those with high levels of bother. general practitioner or specialist nurse. At least three high-quality studies have shown that men with LUTS are at no greater risk of prostate cancer than asymptomatic men of the same age (7-9).6). • providing necessary assistance when there is impairment of dexterity.1 Patient selection All men with LUTS should be formally assessed prior to starting any form of management in order to identify those with complications that may benefit from intervention therapy. Approximately 85% of men will be stable on WW at 1 year.1. mobility or mental state. • WW does not imply no activity. If these men harbour an anxiety about prostate cancer. deteriorating progressively to 65% at 5 years (5. UPDATE MARCH 2004 29 . reassurance. 4. 4. increasing symptom bothersomeness and post-void residual volumes appeared to be strongest predictors of failure. The reason why some men deteriorate with WW and others do not is not well understood. will progress to acute urinary retention and complications such as renal insufficiency and stones (1. WW is a viable option to many men as few. Men with mild to moderate uncomplicated LUTS (causing no serious health threat) who are not too bothered by their symptoms are suitable for a trial of WW. Minor changes in lifestyle and behaviour can have a beneficial effect on symptoms and may prevent deterioration requiring medical or surgical treatment. 36% crossed over to surgery in 5 years leaving 64% doing well in the WW group (4).1 TREATMENT Watchful waiting Many men with LUTS do not complain of high levels of bother and so are suitable for non-medical non-surgical management . • information about prostate cancer is nearly always required. for example at night or when going out in public. • distraction techniques. • bladder re-training. thereby increasing fluid output and enhancing frequency. • avoidance or moderation of caffeine and alcohol which may have a diuretic and irritant effect.4.3 Lifestyle advice Optimization of WW can be achieved with lifestyle modifications. The recommended total daily fluid intake of 1500 mL should not be reduced. if left untreated. flow rates and post-void residual volume measurements are useful in determining whether a patient’s condition has deteriorated. • urethral stripping to prevent postmicturition dribble.2). BPH and LUTS education with the help of written information • reassurance that LUTS does not progress in everyone. symptom bothersomeness.1. Symptom scores. 4. men should be periodically seen by either a urologist.1. It is customary for this type of management to include the following components: education. It is however not possible to guarantee against early undetectable prostate cancer. periodic monitoring and lifestyle advice. such as penile squeeze. • reviewing a man’s medication and optimising the time of administration or substituting drugs for others that have fewer urinary effects. urgency and nocturia. this may focus their attention on specific symptoms and reinforce their fear. by which men are encouraged to ‘hold on’ when they have sensory urgency to increase their bladder capacity (to around 400 mL) and the time between voids. Similarly some men’s symptoms may improve spontaneously whilst others remain stable for many years (3). reassurance and periodic monitoring Although there is little high quality evidence to support this (the studies have not been done) it seems rational to provide the following for men who are candidates for WW: • prostate. Most men over 50 will note changes in their urinary function with or without high levels of bother.

4. J Urol 1994. Again it must be stated that there is little high-quality evidence that provides reliable information on any of these lifestyle activities. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicentre clinical trial of 6.nih.3(Suppl):1-7. http://www. 6. the efficacy of 5-alpha reductase inhibitors is unquestionable and has been demonstrated over large clinical trials.1. Keller AM.ncbi.1 Efficacy and clinical endpoints Today.2.nlm. Wasson JH Anderson RJ. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. Ahmann FR.nih. http://www. 5.nih.5 1. Bruskewitz RC. Br J Urol 1981.53:613-616.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7527493& dopt=Abstract Netto NR http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8630923& dopt=Abstract Rietenberg JBW. Additional value of the AUA 7 symptoms score in prostate cancer (PC) detection.ncbi.ncbi.1.ncbi. Cancer http://www. 4. http://www. Elinson J. 4.1 Finasteride (type 2.nlm. Kranse R. It can reduce the size of the prostate gland by 20-30%. Murphy GP. Bruskewitz RC. The natural history of untreated ‘prostatism’.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933046& dopt=Abstract Catalona WJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=6172172& dopt=Abstract Kirby RS.157:467. http://www. American Cancer Society National Prostate Cancer Detection Project. 7. Feneley RC. http://www.56:3-6. Research in this area is required so that lifestyle advice to men with LUTS can be refined. 4.1. Boeken Kruger AE et al.nih.ncbi.6 mL/s (1-4). D’Ancona CA. http://www.3-1. Flanigan RC.2.fcgi?cmd=Retrieve&db=PubMed&list_uids=1689166& dopt=Abstract Flanigan it improves symptom scores by approximately 15% and can also cause a moderate improvement in the urinary flow rate of 1.fcgi?cmd=Retrieve&db=PubMed&list_uids=11074195& dopt=Abstract Isaacs JT. The results of a five-year early prostate cancer detection intervention.15:1283-1290.• treatment of constipation. Prostate 1990.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7512659& dopt=Abstract Mettlin C.nlm. J Urol 1998. J Urol 1997.nih. 5-year outcome of surgical resection and watchful waiting for men with moderately symptomatic BPH: a department of Veterans Affairs cooperative study. Hudson MA.160:12-16. New Engl J Med 1995.2. after the completion of many trials.1. Netto Evaluation of patients with bladder outlet obstruction and mild international prostate symptom score followed up by watchful waiting.nlm. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. periodic monitoring and lifestyle modifications can be used to optimise WW. 5-alpha reductase inhibitor) 4.ncbi.1. Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention. Scardino PT.nih. Reda DJ. 30 UPDATE MARCH 2004 .77:150-159. Urol 1999. Kavoussi LR.1 5-alpha reductase inhibitors 4. 8.332:75-79.nlm. Henderson WG. Reassurance. de Lima ML.2 Medical treatment 4. 2.630 Further research in this area is required. deKernion JB. Reda DJ.nlm. Richie JP. Ratliff TL. Dalkin BL et al. Abrams PH.fcgi?cmd=Retrieve&db=PubMed&list_uids=9628595& dopt=Abstract Wasson CONCLUSIONS Men with mild to moderate LUTS with low levels of bother are suitable for WW. 3. The natural history of benign prostatic hyperplasia: what have we learned in the last decade? Urology 2000. Babaian RJ. REFERENCES Ball AJ.ncbi.nih.

could predict the best long-term response to finasteride (9). A recent North American study has also verified that long term (10 year) treatment is well tolerated and results in durable symptom relief (13). 4. at the histopathological level. the Scandinavian Finasteride Study Group has verified an earlier observation that the maximum efficacy of finasteride action is obtained after 6 months. double-blind clinical trials have been presented (28. and concluded that doubling the PSA level allowed appropriate interpretation of PSA values and that finasteride treatment did not mask the detection of prostatic adenocarcinomas. multicentre. improve symptoms and urinary flow rate and reduces also the incidence of acute urinary retention and BPH related surgery. In addition. The results of papers dealing with the impact of finasteride on free PSA level are confusing. or enlarged prostate glands. had no significant obstruction or adenocarcinoma of the prostate (14-17). decreased ejaculate (3.1.A meta-analysis of six randomized clinical trials showed that baseline prostate volume was a key predictor of various treatment outcomes and that finasteride was more effective in prostates larger than 40 mL (5). Such side-effects are considered ‘minimal’ since they did not increase over time and did not cause many patients to discontinue their treatment. It was also shown. Thus. Baseline PSA levels of 1. finasteride seemed to lower total and free PSA levels equally. in 4. activity interference and worry due to urinary symptoms.2. A phase II study including 399 patients showed that dutasteride can cause greater suppression of DHT than finasteride (27).1%). In the PLESS study the side effects reported were decreased libido (6. showed that patients with larger prostate volumes or higher PSA levels have an increased risk of developing acute urinary retention and therefore derive the greatest benefit from finasteride therapy (10). The results of four large randomized. Finally it has also been shown that the four year inhibition of type 2 5alpha-reductase with finasteride does not adversely affect bone mineral density (20). and has shown that this improvement could be maintained for at least 6 years (12).1.4 ng/mL.4 Effect on PSA It is known that finasteride lowers serum PSA levels. breast enlargement and breast tenderness (9).29). finasteride-treated patients had significantly less bother. ejaculatory disorders and gynecomastia (28). the question of whether or not it masks the early detection of localized prostatic adenocarcinomas has been raised.4%).7%) and in less than 1% of the patients other disorders such as rash.1.222 men. It has been agreed that 12 months of finasteride. that finasteride did not cause problems in the diagnosis of cancer from needle specimens as cancer tissue remained unaltered (23).22) verified earlier reports. at the same time. reduces serum PSA levels by 50%. In one paper. 4. Three of these studies were placebo controlled studies and they showed that dutasteride can reduce prostatic volume by almost 26%. In a major placebo controlled trial including 3. the percentage of free PSA did not change significantly (25). Data from three multinational. 4.2. so that the ratio of free PSA to total PSA remained unchanged (24).2 Dutasteride It is known that finasteride suppresses dihydrotestosterone (DHT) by about 70% in the serum and by 90% in the prostate. Various studies have confirmed this alternative for patients with haematuria due to BPH who.3 Side-effects These are mainly related to sexual function. Pooled data from the patients enrolled in all four studies proved that dutasteride is well tolerated and adverse events included erectile dysfunction.2 Haematuria and finasteride Another important benefit of finasteride in common clinical urological practice is that it can be used to treat haematuria associated with BPH. 5 mg/day. Dutasteride is a new drug that has the ability to suppress both type 1 and type 2 isoenzymes and as a consequence serum DHT decreases by about 90% (26). In another report. The fourth compared dutasteride with finasteride for one year which showed that drug related adverse events were similar for both compounds. In a recent publication from the PLESS study group it was shown that the finasteride-related sexual adverse experiences occurred mainly during the first year of therapy (18).040 men. The long-term effects of finasteride have also been examined. 4.1. All these figures were higher than those observed for placebo.2.1.2. Various trials have concluded that finasteride significantly reduced acute urinary retention and the need for surgical treatment in men with BPH (6-8). In a recently published study it was also shown that dutasteride UPDATE MARCH 2004 31 .1. placebo-controlled finasteride trials. Another conclusion from the PLESS study was that in both older and younger men with symptomatic BPH. The North American Finasteride Study Group reported that patients treated with finasteride maintained a reduction of prostate volume and an improvement in symptom score and maximal urinary flow rate over a period of 5 years (11). finasteride had the same safety profile and no drug interactions of clinical importance were observed (19). The remaining DHT is the result of type 1 5-alpha reductase activity. impotence (8. Two major studies (21.1.

The follow-up period of the MTOPS trial was 4. Johansson JE. Pommerville PJ. Matsumoto AM. Bruskewitz RC. Kontturi M. Wolf H.5 REFERENCES 1.32). have shown that the combination of finasteride to doxazocin was beneficial (33). Daurio C. Sullivan M. an accurate estimation can be expected. http://www. placebo-controlled double-blinded trial (MTOPS trial). http://www. Roy J.1.nih. Long-term (7 to 8-year) experience with finasteride in men with benign prostatic hyperplasia.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7495111&query_hl=2&itool=pubmed_docsum Gormley GJ. • The long-term (up to 10 years) effects of 5.4 CONCLUSIONS • It has been shown in numerous randomized.1.2.fcgi?cmd=Retrieve&db=PubMed&list_uids=12475666& dopt=Abstract 2. • The combination of a 5-alpha reductase inhibitor with an alpha-blocker seems beneficial according to the data currently available. Maximum benefits are seen at a mean period after 6 months.1. Cook T. Can finasteride reverse the progress of benign prostatic hyperplasia? A two year placebo-controlled study.nlm. Walsh PC.The combination therapy was superior to either drug alone in reducing AUA symptom scores. In another study examining combination therapy. 3. Pappas F.fcgi?cmd=Retrieve&db=PubMed&list_uids=1383816& dopt=Abstract Nickel JC. • 5-alpha reductase inhibitors can alter the natural history of symptomatic BPH by influencing prostatectomy and acute urinary retention rates. Can Med Assoc J 1996.60:1040-104.155:1251-1259. http://www. however. Dutasteride shows similar efficacy and tolerability as finasteride in suppressing both type 1 and type 2 isoenzymes but further randomized studies are needed. N Engl J Med 1992. Ekman P.ncbi. Bracken B.3 Combination therapy The combination of finasteride with an alpha-blocker was examined earlier in two clinical trials (31. and in reducing the likelihood of acute urinary retention and surgery. Perreault 4. Imperato-McGinley J. Bracken BR. The lack of finasteride efficacy in these two trials may be due to smaller baseline prostate volumes.ncbi. • Side-effects of 5-alpha reductase inhibitors are minimal • Treatment with 5-alpha reductase inhibitors does not mask the detection of prostate carcinoma. Stoner E.ncbi. 4. The Finasteride Study Group. should be further evaluated. Geller J. Imperato-McGinley J. Meeha A. 32 UPDATE MARCH 2004 . Elhilali MM. The Scandinavian BPH study group. Recently the results of a multicentre randomized. Beisland HO. placebo-controlled study (SMART study). McConnell JD.5 years and another conclusion drawn from this study was that finasteride needs time to reveal its beneficial therapeutic capacity. No additional benefit from combining these two drugs was observed in either study. it was shown that patients with lower urinary tract symptoms and moderately enlarged prostates initially receiving combination therapy with finasteride and an alpha-blocker were likely to experience no significant symptom deterioration after discontinuing the alphablocker following 9 to 12 months of combination therapy (34). • Men with small prostates (< 40 mL) are less likely to benefit from finasteride. A Lehtonen T. By doubling PSA serum levels. in increasing median maximal flow rates. Efficacy and safety of finasteride therapy for benign prostatic hyperplasia: results of a 2-year randomised controlled trial (the PROSPECT Study).nih. [Symptom Management After Reducing Therapy] associated with clinically significant improvement in BPH specific health status as measured by the BPH Impact Index (BII) (30). et al. Waldstreicher J. The costs of such protocols. 4. 4.nlm. Urology 2002.nlm. Andersen JT. Fradet Y. McConnell J. Afridi SK. Boake RC. Urology 1995. Tenover JS.ncbi. Andriole GL.nih. The effect of finasteride in men with benign prostatic hyperplasia. Tveter K.fcgi?cmd=Retrieve&db=PubMed&list_uids=8911291& dopt=Abstract Vaughan placebo-controlled clinical trials that 5-alpha reductase inhibitors are capable of reducing prostate volume and improving symptom scores and flow rates.alpha reductase inhibitors are substantial.nih.2. Stoner E.46:631-637. on the short term combination of dutasteride and tamsulosin involving 327 patients confirmed compatible results (35).

Roehrborn CG. Malice MP. Ko A.ncbi.nih.nlm. Urology 1999. Maximum efficacy of finasteride is obtained within 6 months and maintained over 6 years. Kantor S. Patterson L.nih. Kashif KM. 15. Geller J.fcgi?cmd=Retrieve&db=PubMed&list_uids=10510926& dopt=Abstract Marberger MJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=9555559& dopt=Abstract Lam JS. 12.nih.nih. Waldstreicher J. Holmes Holmes SA.5.nih. Holtgrewe HL. Rigby O. Efficacy of finasteride is maintained in patients with benign prostatic hyperplasia treated for 5 years. Finasteride Long-term Efficacy and Safety Study Group. Boyle P. Norman R. Anderson R.nih. Stoner E. Lieber MM. Marshall http://www. J Urol 2000.61:354-8. Soloman LZ. http://www. Pappas F. Urology 1996. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride.ncbi. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=9187688& dopt=Abstract McConnell JD. Trachtenberg J.ncbi. The North American Finasteride Study Group. Bruskewitz R. Wedderburn AW. Eur Urol 2000. Cox C. Soloman LZ.38:563-568. Romas NA. Wedderburn AW. Roehrborn CG. Finasteride significantly reduces acute urinary retention and need for surgery in patients with sympomatic benign prostatic hyperplasia.ncbi. Nickel dopt=Abstract Hudson PB.fcgi?cmd=Retrieve&db=PubMed&list_uids=12597947& dopt=Abstract Foley SJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=10197842& dopt=Abstract Ekman P. 7.fcgi?cmd=Retrieve&db=PubMed&list_uids=10647664& dopt=Abstract Foley SJ. 13. Glickman S. N Engl J Med Lowe FC. http://www.ncbi. Summerton D. http://www. Kozlowski D. Nickel JC. http://www.37:528-536.ncbi. 10. Perreault JP. Stoner E.fcgi?cmd=Retrieve&db=PubMed&list_uids=8804493& dopt=Abstract Andersen JT.F. Taylor AM. Prostate volume predicts the outcome of treatment of benign prostatic hyperplasia with finasteride: meta-analysis of randomized clinical trials.fcgi?cmd=Retrieve&db=PubMed&list_uids=9475762& dopt=Abstract Roehrborn CG. Kashif KM. 11. UPDATE MARCH 2004 33 . The Scandinavian Finasteride Study Group.B.ncbi.nlm. Proscar Long-term Efficacy and Safety Study.nlm. Taylor A.nlm. Sullivan http://www.nlm. Urology 2003.49:839-845. Schulman CC. Bruskewitz R. Eur Urol 1998. Waldstreicher J. Characterization of patients and ultimate outcomes.nih.nlm. Andriole G. Bruskewitz RC. Boake R.ncbi. Meehan A. Fowler J. Wang Waldstreicher J. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia.163:496-498.4:670-678. 14.D. Long-term treatment with finasteride in men with symptomatic benign prostatic hyperplasia: 10-year follow-up. Albertsen P. Holtgrewe HL. Gabriel M. Narayan P. Wang D. Herlihy R. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride.ncbi. Bracken R.ncbi.nlm. Urology 1999. Rosenblatt S. Girman CJ. Summerton Waldstreicher J.Effect of finasteride on bother and other healthrelated quality of life aspects associated with benign prostatic hyperplasia.164:1670-1671. Brown BT.338:557-563.nih.nlm. Basketter V. Andersen JT. Fusilier H. Wang D. Prostate volume and serum prostate-specific antigen as predictors of acute urinary retention. Nickel JC. Kandzari S. The PLESS Study Group. Johnson E. Gould AL.nlm. Kornitzer G.A. Elhilali M. 8.nih. Jacobsen CA. Nickel GC. Walsh P. Urology 1997. Follow-up of the Scandinavian Open-extension Study. Malek GH. Romas NA. Eur Urology 2000. 6.53:690-695. PLESS Study Group. Urinary retention in patients with BPH treated with finasteride or placebo over 4 years.nih. http://www. Basketter V. Combined experience from three large multinational placebo-controlled trials. http://www.nlm.48:398-405.fcgi?cmd=Retrieve&db=PubMed&list_uids=10765090& dopt=Abstract Bruskewitz R. Boyle J Urol 2000. Roy JB. http://www. Lieber M.

http://www. Rittmaster RS. Holtgrewe HL. Bach MA.nlm. Urology 1999.nih. Parra R.fcgi?cmd=Retrieve&db=PubMed&list_uids=12639651& dopt=Abstract Kaplan SA. The long-term effect of specific type II 5alpha-reductase inhibition with finasteride on bone mineral density in men: results of a 4-year placebo controlled trial.nlm. Gormley G.fcgi?cmd=Retrieve&db=PubMed&list_uids=12022710& dopt=Abstract 34 UPDATE MARCH 2004 . Pearson JD. Grayhack J.fcgi?cmd=Retrieve&db=PubMed&list_uids=11956450& dopt=Abstract Oesterling JE.167:2489-2491. Subong EN. Roy J.52:195-201. Urology Tenover L.nih.nih. Dihydrotestosterone and the concept of 5 alpha – reductase inhibition in human benign prostatic hyperplasia. http://www. Effects of finasteride and cyproterone acetate on hematuria associated with benign prostatic hyperplasia: a prospective.ncbi. Gormley GJ. Wise H. Bannow J. Waldstreicher J.nih. Treatment with finasteride preserves usefulness of prostate specific antigen in the detection of prostate cancer: results of a randomized. Comparison of the efficacy and safety of finasteride in older versus younger men with benign prostatic hyperplasia.ncbi. PLESS Study Group. Fitch WP. 21.nlm. Mobley D.nlm. Cook TJ.nih. Clinical predictors in the use of finasteride for control of gross hematuria due to benign prostatic http://www. The Finasteride PSA Study Group. terazosin or watchful waiting. Bruskewitz R. Bach M. Catalona Geller J. Cook TJ. Does long-term finasteride therapy affect the histologic features of benign prostatic tissue and prostate cancer on needle biopsy? PLESS Study Group. Proscar Long-term Efficacy and Safety Study. Rajfer J. Gyftopoulos K.nih. http://www. Comparison of percent free prostate specific antigen levels in men with benign prostatic hyperplasia treated with finasteride. Hodge GB.ncbi. Influence of finasteride on free and total serum prostate specific antigen levels in men with benign prostatic hyperplasia. Bannow J. PLESS Study Group.nlm. Andriole GL. Johansen T. Jackson CL. Kadmon D.nlm.50:901-905. Auerbach S.ncbi.ncbi.nlm.19:413-425. Sullivan M. Lee M. Shery ED. Flanagan M. World J Urol 2002. Meehan A. Saltzman B. Lagerkvist M. Proscar Long-term Efficacy and Safety Study. Taylor AM. double-blind. Herlihy R. http://www.nlm.ncbi. Schmidt J.nlm. Kelley CA.nlm. Lecksell K. Fitch W. Roy J.nlm. McClung M. 20. http://www. Klocker H. Labasky R. Culbertson J. Biologic variability of prostate specific antigen and its usefulness as a marker for prostate cancer: effects of finasteride.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377309& dopt=Abstract Matsumoto AM. Patterson L. Waldstreicher J. 25. 23. Barbalias G. http://www. Chan DW. Gottesman J.ncbi. Puchn Urology 1997. Urology 2003. Waldstreicher J. 18. placebo-controlled clinical trial.nih. Shown T.61:579-584.fcgi?cmd=Retrieve&db=PubMed&list_uids=10197843& dopt=Abstract Keetch DW. Lee M.59:373-377. Waldstreicher J.ncbi. Ratliff TL.ncbi. Matsumoto AM.ncbi. Waldstreicher J. Grayhack J. Tenover L. Peterson L. Incidence and severity of sexual adverse experiences in finasterides and placebo-treated men with benign prostatic hyperplasia. controlled study. 26. http://www. PLESS Study Group. Kearney MC. Hudson P.53:696-700. Bergland dopt=Abstract Wessells H. Urology 1998. 19. Markou S. Epstein dopt=Abstract Perimenis P. http://www. Romas NA. Urology 2001.fcgi?cmd=Retrieve&db=PubMed&list_uids=9426721& dopt=Abstract Pannek J. Guess HA. Narayan P. Partin AW.nih. J Urol 2002.fcgi?cmd=Retrieve&db=PubMed&list_uids=9649261& dopt=Abstract Bartsch G. Agha A. Schellhammer PF. J Urol 2002. Meade-D’Alisera P. Wessells H. J Urol 1998.nih. 24. http://www. Stoner E. randomized. Marks LS. Rittenhouse Kadmon D.159:449-453. Epstein JL. Crawford ED.50:13-18. Waldstreicher J. Mobley D. Lund RH. Urology 2002. Rouse S.ncbi.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9218012& dopt=Abstract Andriole GL. Short K.nih. Wells G. Weiner S. Krarup T. Zhang GK. dopt=Abstract Yang XJ. Parra R. Bingham JB.

http://www.ncbi. European ALFIN Study Group. a novel.nih. Discontinuation of alpha-blockade after initial treatment with finasteride and doxazosin in men with lower urinary tract symptoms and clinical evidence of benign prostatic hyperplasia.nlm. 35. Machi M. Ginsberg PC. Sustained-release Gabriel H.nlm. was investigated. 31. Dixon CM. Kirby R Safety and tolerability of the Dual 5 alpha-Reductase Inhibitor dutasteride in the treatment of benign prostatic hyperplasia. Narayan P. Improvements in benign prostatic hyperplasia-specific quality of life with dutasteride.2.nlm.60:434-441.58:203-209. Boyle P. indoramin. Resel L. finasteride. the non-selective alpha-blocker. alpha-blockers were However. prazosin. Jacobi G. Urology 2001.fcgi?cmd=Retrieve&db=PubMed&list_uids=12814679& dopt=Abstract O’Leary MP. Nickel C. http://www. Roehrborn CG. Barry MJ. Urology 2002. On behalf of the ARIA3001. Haakenson C. Taylor S.ncbi.ncbi.nih. N Engl J Med 1996. 34. Roehrborn CG. Delauche-Cavallier MC. Hofner Roehrborn C. alpha-blockers are available (tamsulosin.fcgi?cmd=Retrieve&db=PubMed&list_uids=8684407& dopt=Abstract Debruyne FM.fcgi?cmd=Retrieve&db=PubMed&list_uids=9732187& dopt=Abstract Mc Connell JD. Geffriaud-Ricouard C.ncbi. placebo-controlled clinical studies.fcgi?cmd=Retrieve&db=PubMed&list_uids=11489700& dopt=Abstract Barkin J. Efficacy and safety of a dual inhibitor or 5-alphareductase types 1 and 2 (dutasteride) in men with benign prostatic hyperplasia.44:82-88. Andriole GL. dual 5-alpha reductase inhibitor. Eur Urol 2003. better-tolerated.ncbi.ncbi.335:533-539. http://www. This increase has been driven partly by patients wishing to achieve symptomatic relief without undergoing surgical treatments and partly by the marketing of these drugs by pharmaceutical companies. Hermann D.2 Alpha-blockers Over the past 10 years.fcgi?cmd=Retrieve&db=PubMed&list_uids=12350480& dopt=Abstract Andriole GL. following experimental work demonstrating the predominance of adrenoceptors in human prostate smooth muscle (1). Baldwin KC. Jardin A. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=12887480& dopt=Abstract Lepor H. Morril B.161:1037. they all have a similar efficacy and side-effect profile. ARIA3002 and ARIA3003 study investigators. Andriole G. Harkaway RC. was unacceptable to patients (2. 4.34:169-175. In view of the very real placebo effect seen in the treatment of patients with LUTS secondary to BPH. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract& list_uids=14499682 4. J Urol 1999.nlm. Hoefner K. Brawer MK.167:265. van Vierssen Trip OB. Nickel C.2. McCarthy C. Effective suppression of dihydrotestosterone (DHT) by GI 198745.3). http://www. BJU Inter 2003. 30. Eur Urol 2003. A large number of alpha1-selective.nih. finasteride and the combination of both in the treatment of BPH. 32. due to its unselective nature. Initially. Benign Prostatic Hyperplasia Study Group. Pushkar D.1 Uroselectivity Alpha-blockers were first introduced into clinical practice for the treatment of LUTS secondary to BPH in 1978. abstract 1042.nlm. this review will focus on the results of randomized. alpha1adrenoceptors were identified and selective. Guimaraes M. 33. the prescribing of alpha-blockers has steadily increased. Veterans Affairs Cooperative Studies. phenoxybenzamine. the sideeffect profile. Clarke R.ncbi. alfuzosin. Subsequently. prospective. the novel dual 5 alpha-reductase inhibitor.nih. The long term effects of medical therapy on the progression of BPH: Results from the MTOPS trial. Broadly doxazosin. Eur Urol 1998. Boyle PJ.nlm. Gormley G. Padley RJ. Witjes WP.nih. J Urol 2002. Colloi Williford WO.nih. or both in benign prostatic hyperplasia. Wilson T. UPDATE MARCH 2004 35 . 29. Hobbs S. The efficacy of terazosin. terazosin).gov/entrez/query. http://www. Alpha-blocker therapy can be withdrawn in the majority of men following initial combination therapy with the dual 5alphareductase inhibitor dutasteride.

2. Because of this. Patients may choose to stop taking medication for a number of reasons. Currently there is no method of predicting which men will show a response (4). 36 UPDATE MARCH 2004 . The optimal duration of the trial of therapy has been debated. although flow rates do improve with these agents relative to placebo.2. without catheter. Most men experience re-retention within the first two months (13).2 Mechanism of action Alpha-blockers are thought to act by reducing the dynamic element of prostatic obstruction by antagonizing the adrenergic receptors responsible for smooth muscle tone within the prostate and bladder neck.2. Djavan and Marberger’s meta-analysis estimated that overall symptoms improved by 30-40% and that flow rates improved by 16-25%.2. Two trials have looked at alfuzosin (11). the exact contributions of alpha1-receptor subtypes and the potential central effects in vivo remain unclear. Symptoms can improve within 48 hours.6 per month. As a result. 4. However. once-daily preparations. dizziness. and one at terazosin (12). Drop-outs occurred at the same rate. An I-PSS assessment requires at least one month of therapy.01 and 1. 4. namely. Urodynamic studies measuring voiding pressures do not reveal any significant relief of obstruction.2.2. Studies have concentrated on two important reasons.3 Pharmacokinetics Alpha-blockers are taken orally and the dosage depends on the half-life of the relevant drug. Studies are underway which address the question of whether men do benefit from alpha-blockade in the six months following acute urinary retention.2. postural hypotension. in this context these types of design are informative. asthenia. In general. Whether this translates into a reduction in clinical side-effects remains to be seen. Predicting response for any individual is more difficult and therefore a trial of therapy is required.2.2. There is no evidence that efficacy diminishes with time. The effect seems to be independent of the type of alpha-blocker studied.6 Durability Good data on long-term efficacy and the effect on natural history are currently not available. 4. following an episode of acute urinary retention. drowsiness. 4. irrespective of whether symptoms were moderate or severe. the occurrence of adverse effects and lack of efficacy (8). There is no justification in prolonging therapy beyond one month in men who do not respond. 4. Tamsulosin resulted in less orthostatic hypotension than alfuzosin under test conditions. secondary publications that have compared outcomes between these studies have been useful (5-7). Long-term studies tend to be open-label extensions or increasingly ‘real life practice’ studies which do not conform to an experimental design. The various types of alpha-blockers cannot be distinguished by their ability to relieve symptoms or improve flow. compared with placebo (6). 4. This is implied from in-vitro experiments and the predominant distribution of alpha1-receptors within the prostate and bladder neck. Tamsulosin. nasal congestion and retrograde ejaculation (6). a large number of urologists have adopted this practice.4.4 Assessment It is not unreasonable to offer a trial of alpha-blockers to all men with uncomplicated LUTS. The rate of drop-out in men on alpha-blockers appears to be between 0. the rate of sideeffects in studies looking at tamsulosin and alfuzosin were equivalent to placebo (4-10%). the symptom status of men did not predict whether they were likely to stop therapy. In general.2.2. Nevertheless.7 Adverse effects The most commonly reported side-effects with alpha-blocker therapy are headaches.2. None of these trials continued therapy beyond the period of catheterization. terazosin and doxazosin have the advantage of being long-acting.2. alfuzosin.8 Acute urinary retention Early trials comparing alpha-blockers to placebo showed an increased likelihood of a successful trial. One-third of men will not experience significant symptom reduction.2.5 Clinical efficacy The interpretation of existing literature regarding the efficacy of alpha-blocker therapy is clouded by the wide discrepancy in methodology and reporting of clinical studies.

gov/entrez/ Perlberg S. Alpha blockers: are all created equal? Urology.50:551-554. Debruyne FM. Review.nlm.nih. Caris CT. placebo-controlled studies. Br J Urol 1978. Long-term quality of life in patients with benign prostatic hypertrophy: preliminary results of a cohort survey of 7093 patients treated with alpha-1 adrenergic blocker.49:197-205. Shah PJ. • There is no difference between different alpha-blockers in terms of efficacy.fcgi?cmd=Retrieve&db=PubMed&list_uids=11074198& dopt=Abstract 8. Paris. Caine M. Urology 1998.nlm. Witjes WP. prostatic capsule and bladder neck. Lepor H.nlm.ncbi. Raz S. treatment should be discontinued. Lukacs B. 610-632. Zeigler M. Griffiths K. Urology 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=6184106& dopt=Abstract 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=1148621& dopt=Abstract 2. http://www.ncbi. Delauche-Cavallier MC. These changes have been shown to be significant in randomized.nlm. Debruyne FMJ. http://www. Khoury S et al. http://www. Eur Urol 1998. finasteride and the combination of both in the treatment of benign prostatic hyperplasia. Plymouth: Health Publications. Choa RG.ncbi. Adrenergic and cholinergic receptors in the human prostate.fcgi?cmd=Retrieve&db=PubMed&list_uids=10364649& dopt=Abstract 7. A stratified analysis. supportive data are weak. Urodynamic and clinical effects of terazosin in symptomatic patients with and without bladder outlet obstruction. Rosier PF.ncbi. July 1997. • Patients should be informed about the side-effects of alpha-blocker therapy and the need for longterm use. Meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. McCarthy Stone AR. Geffriaud-Ricouard C.56(5 Suppl 1):20-2.fcgi?cmd=Retrieve&db=PubMed&list_uids=88984& dopt=Abstract 3. Bladder outflow obstruction treated with QOL BPH Study Group in General Practice.ncbi. In: Denis L.fcgi?cmd=Retrieve&db=PubMed&list_uids=9037281& dopt=Abstract 5. http://www.9 CONCLUSIONS • Alpha-blocker therapy can result in a rapid improvement in symptoms by a factor of 20-50% and an improvement in the flow rate of 20-30%.nlm. Eur Urol 1999. Chapple CR.nih.nih.34:169-175. European ALFIN Study Group. de la Rosette JJMCH. Witjes WP.24(Suppl 1):34-40. If a patient does not experience an improvement in symptoms after an 8-week trial. Debruyne FMJ. Colloi D.10 REFERENCES 1. • Long-term data are limited but suggest that the benefits of treatment are sustained. Andersson KF. 6.2. Br J Urol 1982. Long-term evaluation of tamsulosin in benign prostatic hyperplasia: placebo-controlled.nlm.nih. Abrams PH. Although the side-effect profiles for some drugs are reported to be more favourable.fcgi?cmd=Retrieve&db=PubMed&list_uids=7687557& dopt=Abstract 9.ncbi. Eur Urol 1993. double-blind extension of phase III trial. Meretyk S. 2000. Marberger M.4.2. http://www.ncbi.ncbi. A placebo controlled double blind study of the effect of phenoxybenzamine in benign prostatic obstruction. Resel L. Jardin A.nlm. pp.nlm. Tamsulosin Investigator Group. α-blockers clinical results.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9609624& dopt=Abstract 10. Caine M. Grange JC. dopt=Abstract UPDATE MARCH 2004 37 .36:1-13. Proceedings of the Fourth International Consultation on BPH.nih.47:193-202. Sustained-release alfuzosin.2. eds. Bono VA et al. McCarthy C. 4. alfuzosin. Djavan B.nih. Br J Urol 1975.51:901-906.nih.

nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=12022711& dopt=Abstract Eur Urol 2002.fcgi?cmd=Retrieve&db=PubMed&list_uids=11753128& dopt=Abstract Lowe FC.nih.nih. http://www.(1):CD001044.ncbi.ncbi. Raynaud JP. 58(Suppl 1):71-76. Da Silva FC. Wong WS. Urol Clin North Am 2002. A few short term randomized trials and some meta-analyses show clinical efficacy without major side effects for compounds such as Pygeum africanum and Serenoa repens (1-4). These agents are composed of various plant extracts and it is always difficult to identify which component has the major biological activity.ncbi. Cochrane Database Syst Rev 2000. Vela-Navarrete R.1 CONCLUSIONS The mode of action of phytotherapeutic agents is unknown. Stark G. 3.nih.3 Phytotherapeutic agents The use of phytotherapy in treating lower urinary tract symptoms and benign prostatic hyperplasia has been popular in Europe for many years and has recently spread in the dopt=Abstract Dreikorn K. Fagelman E. Wilt T.1:27. Sustained-release alfuzosin and trial without catheter after acure urinary retention: a prospective placebo-controlled.fcgi?cmd=Retrieve&db=PubMed&list_uids=10796790& dopt=Abstract Fagelman E. Shearer MG. 5. Serenoa repens for benign prostatic hyperplasia.nlm. Lowe FC. Chan LW.ncbi. Rutks I.fcgi?cmd=Retrieve&db=PubMed&list_uids=11750257& dopt=Abstract Debruyne F.nlm. Cheng CW. 4.41:497-506. is also included to this chapter. McNeill SA. Phytotherapy in the management of benign prostatic Urol 2000. Hargreave TB. Mitchel I-D. Many questions concerning the composition.nih.nlm. Pygeum africanum for benign prostatic hyperplasia. Koch G. Daruwala PD. Curr Opin Urol 2002. Cochrane Database Syst Rev http://www. 6. an electrosurgical modification of the TURP-technique. 13. Boyle P. Stark G. Phytotherapy in the treatment of benign prostatic hyperplasia.fcgi?cmd=Retrieve&db=PubMed&list_uids=12109350& dopt=Abstract Lowe FC.2 REFERENCES 1.nlm.77:Suppl. the extraction and the mechanism of action of these compounds still remain unanswered and therefore additional randomized. Two randomized controlled trials (RCTs) are available 38 UPDATE MARCH 2004 . 4.nih.3. World J Urol 2002. Mac Donald R. Mitchell I-DC. http://www. Rizvi S. Transurethral vaporisation.11.ncbi.nih. 12. Mac Donald R. transurethral incision of the prostate (TUIP) and open prostatectomy are the conventional surgical options. Teillac P.nlm. 7.2. 4. Ishani A.fcgi?cmd=Retrieve&db=PubMed&list_uids=11869585& dopt=Abstract Wilt T. The role of phytotherapy in treating lower urinary tract symptoms and benign prostatic hyperplasia. Gillenwater JG.nih. http://www. http://www.ncbi. Lau J.84:622-627.19:426-435. The biological effects in unclear although a few randomized clinical trials show encouraging results.ncbi. Comparison of a phytotherapeutic agent (Permixon) with an alphablocker (Tamsulosin) in the treatment of benign prostatic hyperplasia: a 1-year randomized international study. http://www. 4.nih. Mulrow C. Hamdy FC. Daruwala PD. Gallagher H.(3):CD001423. Ishani A. McNeil SA. Can terazosin (alpha blocker) relieve acute urinary retention and obviate the need for an indwelling urethral catheter? Br J Urol 1996.163:307. BJU Int 1999.29:23-239. Herbal medications in the treatment of benign prostatic hyperplasia (BPH). Hargreave TB.3 Surgical management Transurethral resection of the prostate (TURP). Long term follow-up following presentation with first episode of acute urinary retention. http://www. placebo controlled trials are needed (7).fcgi?cmd=Retrieve&db=PubMed&list_uids=10510105& dopt=Abstract Chan In some studies the efficacy of these compounds was found to be equivalent to finasteride and α-blockers (5. Perrin P. Urology 2001.

while TURP.3. minimal risk of bleeding and blood transfusion. Following TUVP. However. TUIP has several advantages has several advantages over TURP. The highest Qmax improvement (+175%) is seen after open prostatectomy (absolute numbers: 8. As RCT-data are not yet available. decreased risk of retrograde ejaculation and shorter operating time and hospital stay. A recent RCT has shown that Holmium-laser enucleation leads to similar outcome as open prostatectomy for men with large glands (> 100 mL) at a significantly lower complication rate (11). yet a higher long-term failure rate. Mean improvement of LUTS in a meta-analysis of 29 RCT with a TURP-arm was 71% (range: 66-76%) (6). The following complications of BPH/BPE are considered strong indications for surgery: • refractory urinary retention • recurrent urinary retention • recurrent haematuria refractory to medical treatment with 5-alpha reductase inhibitors • renal insufficiency • bladder stones. The UPDATE MARCH 2004 39 . Encouraging data are available for all these techniques.2-22. -60% after TUVP.3 Perioperative antibiotics A known urinary tract infection should be treated before surgery (15. -60% after TURP.3.4). particularly for patients with bleeding disorders and small prostates. In the 10 RCTs comparing TURP to TUIP. Increased post-void residual volume may also be used as an indication for surgery. The RCTs comparing TURP to TUVP also revealed similar improvements of LUTS in both study arms (6). the Qmax increased by 155% (range: 128-182%) (6). there is a great intra-individual variability and an upper limit requiring intervention has not been requiring intervention has not been defined. serum Na+ < 130 nmol/L) is in the range of 2%. They showed similar improvements of LUTS in patients with small prostates (< 20-30 mL) and no middle lobe (5-7). The risk of a TUR-syndrome (fluid intoxication. these methods are not described in more detail below. The routine use of prophylactic antibiotics remains controversial. or if resection of bladder diverticula is indicated (8-10). prolonged operation time. the data of large scale RCT are awaited with interest (12-14).4 Treatment outcome LUTS All four surgical procedures (TURP. Coagulating intermittent cutting. 4. TUIP and TUVP have been subjected to a number of RCTs.3. 4. TUIP. TUVP and open prostatectomy) result in an improvement of LUTS exceeding 70%. Open prostatectomy is the treatment of choice for large glands (> 80-100 mL).8-10). both procedures resulted in a similar improvement in symptoms after 12 months (5-7). antibiotics are recommended in patients on catheterisation prior to surgery.6 mL/s) (6). in absolute terms + 9. rotoresection and bipolar electrocautery are electrosurgical modifications of the conventional technique (12-14).7 mL/s (range: 4-11. Variables that most likely predict the outcome of prostatectomy are severity of LUTS. large glands and past or present smoking (20). associated complications such as large bladder stones. TUVP is considered an alternative to TUIP and TURP. 4.6 mL/s) (6.16).17-19).1 Indications for surgery The most frequent indication for surgical management is bothersome LUTS refractory to medical management (1. Uroflowmetry The mean increase of Qmax following TURP is 115% (range: 80-150%) (6).2 Choice of surgical treatment Ten RCT comparing TUIP to TURP are available (5-7).and postoperative complications are correlated with the size of the prostate and the length of the procedure. such as a lower incidence of complications.25% in contemporary series (6. 4.3.for open prostatectomy. 4. Risk factors for the development of the TUR-syndrome are excessive bleeding with opening of venous sinuses. the degree of bother and the presence of BPO (see above) (3. and –55% after TUIP (4-11).3. However. Post-void residual volume All four surgical procedures allow a reduction of the post-void residual volume of more than 50%: -65% after open prostatectomy. TURP comprises 95% of all surgical procedures and is the treatment of choice for prostates sized 30-80mL.5 Complications Intra-/peri-operative Mortality following prostatectomy has decreased significantly within the past two decades and is less than < 0. Intra. with open prostatectomy leading to slightly superior results (4-11).2).

TURP. Wasson JH. • with a strong indication for surgery. such as age. http://www. one RCT reported an incontinence rate of 5% (6.fcgi?cmd=Retrieve&db=PubMed&list_uids=9634047& dopt=Abstract Bruskewitz RC. National Prostatectomy Audit Steering Group.8 1.ncbi.nih. particularly TURP.ncbi.ncbi. 4.nlm. 4. Reda DJ. Sands JP.3. 2. The risk of bladder neck contracture is Roberts JL. A secondary prostatic operation is reported at a constant rate of approximately 1-2% per year (4-11). These findings have not been replicated by others (17.7% after TUIP (4-11). There is a long-standing controversy on the impact of prostatectomy. yet who do not improve after non-surgical (including medical) treatment. • TUIP is the surgical therapy of choice for men with prostates < 30 mL and no middle lobes. Ward JF. 4% after TURP and 0. J Urol 1999. http://www.3.fcgi?cmd=Retrieve&db=PubMed&list_uids=9120927& dopt=Abstract 2.8% after TURP and 1.6 Long-term outcome Retreatment rate Favourable long-term outcome is common after open prostatectomy.nlm. J Urol 1997.19. Barrett L. The frequently reported rise of erectile dysfunction after TURP is therefore most likely not a direct consequence of TURP but rather caused by confounding factors. Bladder neck contracture and urethral stricture: The risk of developing an urethral stricture is 2. The management of men with acute urinary retention. 3. All four surgical procedures have been evaluated in randomised controlled trials. 40 UPDATE MARCH 2004 . Long-term risk of mortality The possibility of an increased long-term risk of mortality after TURP compared to open surgery has been raised by Roos et al.3. Emberton M.22). In addition: • Surgical prostatectomy (open.estimated need for blood transfusion following TURP is in the range of 2-5%. In the 29 RCTs recently reviewed.4% after TUIP (4-11). who not want medical treatment but who request active intervention. The respective figures for TUVP are in the range of TURP (6). TUIP.fcgi?cmd=Retrieve&db=PubMed&list_uids=10492185& dopt=Abstract Pickard R. REFERENCES Borboroglu PG. TUVP) results in significant subjective and objective improvements superior to medical or minimally invasive treatment.6% after open prostatectomy.5% (95% Cl: 0. http://www. Phelan M. Kane CJ.8% following TUIP. Testing to predict outcome after transurethral resection of the prostate. 3. on erectile function. Long-term complications Incontinence: Median probability for developing stress incontinence ranges is 1.157:1304-1308. Few data are available on the long-term outcome following TUVP. Br J Urol 1998.nih. (18).2% following The only RCT that compared TURP to a “wait and see” policy reported identical rates of erectile dysfunction in both arms (4). Higher percentages have been reported following open prostatectomy (6.8-10).7 CONCLUSIONS AND RECOMMENDATIONS Surgery should be considered for those men: • who are moderately/severely bothered by LUTS. Sexual function: Retrograde ejaculation results from the destruction of the bladder neck and is reported in 80% after open • with bothersome LUTS.8% after open surgery. Limited information on this issue is available for TUVP.nih. Immediate and postoperative complications of transurethral prostatectomy in the 1990s. The risk of bleeding following TUIP and TUVP is negligible (6). and up to 10% following open prostatectomy (4-11).162:1307-1310.21).7%) (6). TURP and TUIP. 65-70% after TURP and 40% after TUIP (4-11). Neal DE. 4. the incidence of erectile dysfunction following TURP was 6.81:712-720.2-12.

The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. Fondacaro Pavone-Macaluso M for the members of the Sicilian-Calabrian Society of A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. Rotoresect for bloodless transurethral resection of the prostate: a 4-year follow-up. Luftenegger W. 14. Abrams P. Gahli AM. Eur Urol 1998. 7.nih. Keller AM. Transurethral incision compared with transurethral resection of the prostate for bladder outlet obstruction: a systematic review and meta-analysis of randomised controlled trials.ncbi. Melloni D. Elinson J. Leyh H. Donovan JL.fcgi?cmd=Retrieve&db=PubMed&list_uids=11435849& dopt=Abstract Mearini Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate. Marzi M.ncbi. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11342911& dopt=Abstract Madersbacher Miano L. Bruskewitz RC.fcgi?cmd=Retrieve&db=PubMed&list_uids=9831789& dopt=Abstract Serretta V. 15.21:112-116.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=12352419& dopt=Abstract Hartung R. http://www. The provision of transurethral prostatectomy on a day-case basis using bipolar kinetic technology.81:827-829. http://www. Prajsner A. http://www.ncbi. 8.ncbi.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=12385922& dopt=Abstract Kuntz RM.ncbi. Knoll T.ncbi.nih. http://www.nih. Vicentini C. http://www. 10. Holtl Henderson WG.nlm.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=11942959& dopt=Abstract Elmalik EM. Carter S. J Urol 2002. Orestano F. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions. Harmuth H. http://www. 11. in patients with benign prostatic hypertrophy. http://www. Wolf D. Eur Urol 2001. http://www.168:1465-1469. 16. Fastenmeier K.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=10705199& dopt=Abstract Scholz M. A prospective study of the safety and efficacy of suprapubic transvesical prostatectomy in patients with benign prostatic hyperplasia.nlm. Liapi C. Hind A. Bahar YM.91:65-68.nlm. Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100grm: a randomised prospective trial of 120 patients.nih.nih.nih. Wilt TJ. Br J Urol 1998. http://www. J Urol 2001.nlm. Pirritano D. Mearini L. Morgia Neurourol Urody 2002. 9. Saad MS. J Urol Urology 2002. Open prostatectomy in benign prostatic hyperplasia: 10-year experience in Risk factors in prostatectomy bleeding: preoperative urinary tract infection is the only reversible factor. LoBianco A. Wasson dopt=Abstract Eaton AC. Porena M.nlm.nih.ncbi.nlm. Francis RN. BJU Int 2003. Zucchi A. Eur Urol 2000. http://www.nlm.nih. Kohrmann KU. 12.165:1526-1532. Coagulating intermittent Improved highfrequency surgery in transurethral prostatectomy. Trojan L. Curto G. Barba M.fcgi?cmd=Retrieve&db=PubMed&list_uids=9666765& dopt=Abstract UPDATE MARCH 2004 41 .ncbi. Ibrahim AI.166:172-176.fcgi?cmd=Retrieve&db=PubMed&list_uids=11857663& dopt=Abstract Tubaro A.fcgi?cmd=Retrieve&db=PubMed&list_uids=11464057& dopt=Abstract Michel MS.fcgi?cmd=Retrieve&db=PubMed&list_uids=10233485& dopt=Abstract Tkocz M.nlm. 13. Lehrich K. 6. Alken P. Marberger M. http://www. BJU Int 2002. Motta M. Reda DJ. Is transurethral resection of the prostate still justified? Br J Urol Peters TJ. http://www. New Engl J Med Single-dose antibiotic prophylaxis in transurethral resection of the prostate: a prospective randomized trial.fcgi?cmd=Retrieve&db=PubMed&list_uids=7527493& dopt=Abstract Yang Q.

as far as durability is concerned. http://www.2). http://www. Smoking increases the risk of large scale fluid absorption during transurethral prostatic resection. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. Muto G. Long-term incidence of acute myocardial infarction after open and transurethral resection of the prostate for benign prostatic hyperplasia. Fredman B. Breda G. In addition. http://www. In subsequent years. The use of contact lasers using a bare fibre has been abandoned. This effect decreases forward scatter into tissue and may cause less tissue oedema. Eur Urol 1998.nlm. Perachino M. randomised clinical study on 150 patients.fcgi?cmd=Retrieve&db=PubMed&list_uids=10444122& dopt=Abstract Roos NP.nih.nlm.5).gov/entrez/query. Shpitz B. Holmium:YAG. Puppo P. Comeri 20. Persson PG. side-firing Nd:YAG laser instrument (the TULIPTM device) for BPH therapy appeared in the urological literature (7. resulting in marked improvement in their voiding symptoms. There is also secondary tissue slough.1 Laser types Four types of laser have been used to treat the prostate: Nd:YAG. Pappagallo GL.84:37-42. reports describing a This consisted of a gold-plated mirror affixed to the distal end of a standard. Transurethral electrovaporization of the prostate vs. delivered via an optical fibre equipped with a distal reflecting mechanism. Mortality and prostate cancer risk in 19.ncbi. which cause the tissue to be dehydrated (4. Holman CD. Hallin A. which is associated with tissue oedema. Urology 2000. Wisniewski KTP:YAG and diode. Interstitial treatments depend on inserting the fibre into the prostatic tissue and the use of coagulation techniques (6). Rouse IL. Guazzieri J Urol 1999. transurethral resection.598 men after surgery for benign prostatic hyperplasia. Resection of a multicentric. right-angle fibre or interstitial fibre. Fisher ES.nlm. 21.166:162-165. N Engl J Med 1989. flexible. the TULIPTM device was abandoned and other authors experimented with even greater prostatic tissue ablation using a much simpler side-firing Nd:YAG laser delivery system. Francesca F.fcgi?cmd=Retrieve&db=PubMed&list_uids=10688086& dopt=Abstract Hahn RG. energy levels can be varied to achieve coagulation or vaporization. http://www. Fortunato P. Hammar N.fcgi?cmd=Retrieve&db=PubMed&list_uids=9915433& dopt=Abstract 4. 19. These. Malenka DJ.161:491-493. 22. However.nih. 4. reports documented the fact that prostatic tissue ablation could be achieved using the Nd:YAG laser.8).4.nlm. The difference between coagulation and vaporization is that coagulation causes little vaporization and depends on temperature changes to achieve permanent tissue damage. Boccafoschi C. Incidence of acute myocardial infarction and cause-specific mortality after transurethral treatments of prostatic hypertrophy.ncbi. long-term follow-up results are only available from initial studies. Wennberg JE. when Shanberg et al. 4.4. Ramsey E. Kessler O. Andersen TF.320:1120-1124. 18.nlm.4 Lasers The use of lasers to treat BPH has been contemplated since 1986 but was anecdotal until the early 1990s (1. Nissenkorn I. http://www. Bass AJ. Operative technique Side-firing laser prostatectomy is performed using Nd:YAG laser light at 1064 nm and relatively high power settings (typically between 40 and 80 W).nih. Richter S.fcgi?cmd=Retrieve&db=PubMed&list_uids=2469015& dopt=Abstract Hahn RG. Vaporization depends upon temperature changes of over 100oC. http://www. McPherson Right-angle fibres From 1991 onward. This fibre fits through standard cystoscopes and all laser applications are performed 42 UPDATE MARCH 2004 . Semmens JB.fcgi?cmd=Retrieve&db=PubMed&list_uids=9612677& dopt=Abstract Shalev M. (3) reported the use of the Nd:YAG laser to perform prostatectomy in 10 patients with BPH.fcgi?cmd=Retrieve&db=PubMed&list_uids=11435847& dopt=Abstract Gallucci M. and other. BJU Int 1999.nih. laser transmission fibre (UrolaseTM fibre) (9).ncbi. Cohen MM. Mandressi A. silica-glass. Farahmand BY.ncbi. the results of many studies have been published.nlm. With the development of the right-angle fibre and the refinement of both equipment and technique.55:236-240. J Urol 2001. Energy can be delivered through a bare fibre.

but again documented differences in morbidity between these operations. Disadvantages are the delayed time to normal voiding and severe dysuria (8.8% of these patients underwent TURP because of recurring obstruction. The UPDATE MARCH 2004 43 . Retrograde ejaculation has been reported in up to 22% of patients. durability and limitations There have been many studies comparing side-fire laser to TURP.12. these techniques.13). An improvement in voiding produced by side-firing Nd:YAG laser prostatectomy has been extensively documented in the urological literature. regional or systemic anaesthesia. randomized. in larger glands significant amounts of obstructive prostatic tissue can be left behind (17). Indigo. If randomized studies are considered. Catheter irrigation is generally not required and blood loss is statistically lower with Nd:YAG laser coagulation than with TURP because of the excellent haemostasis produced. with local. Moreover. emergent TURP has been reported to solve this problem (8). sparing its urethral surface. it is possible to coagulate any amount of tissue at any desired location. favouring laser prostatectomy as a much safer procedure than TURP (12. All patients had undergone pressure-flow studies at 3 months after laser treatment: 32 previously obstructed patients were unobstructed. TURP and TUIP. These data therefore suggest caution in giving indications to laser treatment. offer better long-term results and comparable (if not superior) efficacy than laser prostatectomy. an Italian retrospective study of 36 patients submitted to side-fire Nd:YAG laser prostatectomy with a minimum follow-up of 5 years reported striking results (23). The objective of ILC of BPH is to achieve marked volume reduction and to decrease urethral obstruction and symptoms. The best results are obtained if the weight of the gland is below 50-60 g. The major limitation of the laser technique compared with conventional TURP is the lack of immediate effect and requirement for urinary catheter drainage for several post-operative days. These authors reported that 78. or under local peri-prostatic block as described by Leach et al. Such a retreatment rate is definitely greater than that observed after TURP and even after TUIP. several studies have demonstrated the ability of side-firing laser prostatectomy to produce a significant improvement in bladder outflow obstruction. Dornier. serious treatment-related complications occurred in 11. 4. The most commonly used fibres are ITT Light GuideTM. (18) reported that 85% of men undergoing laser prostatectomy could expect at least a 50% improvement in either prostate symptom score or peak urinary flow rate. and most patients do not notice significant benefits until approximately 3-4 weeks post-operatively. Costello et al. Operative technique Fibres employed for ILC must emit laser radiation at a relatively low power density. With regard to durability. the results are quite similar.3 ILC ILC as a therapy for BPH was first mentioned by Hofstetter in 1991 (25). The operation may be performed under general or regional anaesthesia.19-21).approximately 2% per year of followup . and the Diffusor-TipTM. several variations and technical and procedural developments have been introduced and tested in clinical trials (26).1% of TURP patients. although they are higher in the TURP arms (12-17). 43. prospective evaluation. These laser applications are repeated systematically and with considerable overlap until all visible obstructing prostatic tissue has been coagulated (11). an improvement in voiding occurs only gradually. The operating time is approximately 45 minutes or less. showing an equivalent improvement in symptom scores and increases in uroflow rates in both groups. After 5 years. Nd:YAG lasers or diode lasers are used for ILC. particularly in patients who are candidates for TURP or TUIP.or 6-months of post-operative follow-up. ILC can be carried out using the transurethral approach. Optimal tissue ablation is achieved using long-duration (60-90 seconds) Nd:YAG laser applications to fixed spots along the prostatic urethra. Both the US and UK multicentre trials documented dramatic differences in serious treatment-related complications. the observed retreatment rates following laser prostatectomy . Since then. Some patients may require catheterization for 3-4 weeks or more (24). men with chronic urinary tract infections and chronic bacterial prostatitis are not good candidates for Nd:YAG laser coagulation of the prostate (18) because of the possibility of infection of the necrotic tissue that remains in situ for several weeks after the operation. No study has reported any occurrence of impotence or sustained incontinence. Coagulation necrosis is generated within the adenoma. In fact. Further long-term follow-up studies are needed. Post-procedure. Outcome.22).6-95% of men undergoing laser treatment were rendered unobstructed at 3.4. As far as complex urodynamic evaluation is concerned. During the 3-year post-operative follow-up. (10). As the applicator can be inserted as deeply and as often as necessary. (14) found equivalent voiding outcomes for the two procedures.8% of laser prostatectomy patients and 35. Results of pressure-flow studies have been reported by several authors (8. Even after catheter removal.seem comparable to documented reoperation rates after TURP (18). the intraprostatic lesions result in secondary atrophy and regression of the prostate lobes rather than sloughing of necrotic tissue (27). Kabalin et al.transurethrally under the direct visual control of the surgeon. In a single-institution. Conversely. morbidity.

the longest available follow-up is only 12 months. randomized trial comparing TURP with HoLRP.0001) and length of hospital stay (26. Urethral strictures or bladder neck strictures are not common. and certain disadvantages. obstruction and enlargement. Currently. The retreatment rate is up to 15.31. sufficient to obtain adequate haemostasis (38). A continuous flow resectoscope is required with a working element. primarily TURP. Outcome. such as urgency (25). 47. four ILC patients (8. 120 patients with urodynamic obstruction have been enrolled with prostates less than 100 g in size (Schafer grade 2). As for morbidity. rising to 9. although the catheter was removed within 10 days in more than 70% of cases. Symptomatic and urodynamic improvement were equivalent in the two groups. 25. normal saline is used as the irrigant. Urodynamic parameters were also measured before and after ILC treatment (32.6% thereafter (36).39). Post-operative irritative symptoms have been observed in 5-15% of patients (28. As a general guideline. only a few studies with a short follow-up have been published to date. Unfortunately.8 minutes. In general. 44 UPDATE MARCH 2004 . durability and limitations As this technique is relatively new. further comparative randomized studies with longer follow-up are needed to assess the durability of this procedure. the retreatment rate is expected to be higher. residual urine volume and prostate volume (26-31). Outcome.0001) for HoLRP patients. such as almost no serious morbidity. the results of only one long-term follow-up study are available (36). one or two placements are used for each estimated 5-10 cm3 of prostate volume. there is a temporary increase of obstruction after ILC. The basic principle of the technique consists of retrograde enucleation of the prostate and fragmentation of the enucleated tissue to allow its elimination through the operating channel of the resectoscope (38. solid-state laser that has been used in urology for a variety of endourological applications in soft tissues and for the disintegration of urinary calculi (37). p < 0. Muschter et al.38). This procedure can be seen as a true alternative to TURP in selected patients with some advantages. The Ho:YAG wavelength is strongly absorbed by water and the zone of coagulation necrosis in tissue is limited to 3-4 mm. Pressure-flow studies demonstrated a sufficient decrease of the intravesical pressure. durability and limitations Studies were performed to compare the results with ILC with those of other laser techniques. All studies reported marked improvements in symptom score. such as the need for longer post-operative catheterization and the lack of tissue for biopsy. clearly demonstrating that HoLRP is associated with significantly shorter catheter time and a lower incidence of post-operative dysuria (41). p < 0. the sites for fibre placement are chosen according to where the bulk of hyperplastic tissue is found (26). morbidity.4 hours. the retreatment rate was 3. there were no statistical differences between groups for all the considered parameters. Comparative studies of Nd:YAG versus prostatectomy have been conducted.9%. p < 0. Post-operative catheterization was required for an average of up to 18 days.0001). and have been reported in approximately 5% of patients.4. 48 patients received ILC and 49 underwent TURP (34). ILC can be performed in small prostates and also seems to be suitable to debulk larger prostates or to treat highly obstructed patients (26). (40) presented the results of a prospective. but a shorter mean catheter time (20.2 hours.laser fibre is introduced from a cystoscope within the urethra. Operative technique Instrumentation for this technique includes a 550-µm end-firing quartz fibre and an 80-W Ho:YAG laser.34). Within 12 months. which has confirmed the shortterm durability of the procedure (36).1% per year in the first year. although as follow-up becomes longer. though retrograde ejaculation was occasionally reported. urethral opening pressure and urethral resistance. However.35). 4.4 vs. The total number of fibre placements is dictated by the total prostate volume and configuration. peak flow rate. Prostatectomy using this energy source is a relatively new technique with the first patient reports appearing in 1995 (37. Gilling et al. The peak power achieved results in intense tissue vaporization and in precise and efficient cutting ability in the prostatic tissue.4% with a maximum follow-up of 12 months. No study has reported any occurrence of impotence or sustained incontinence. In 394 patients followed for up to 3 years.1 vs.33). with an incidence ranging from 0-11.0 vs. so far. morbidity. The results of several studies indicated the effectiveness of ILC in treating BPH with regard to symptoms. Preliminary analysis has revealed a longer mean resection time (42.3%) were considered to be treatment failures and underwent TURP. which can result in urinary retention and temporary irritative symptoms.4 Holmium laser resection of the prostate (HoLRP) The Holmium laser (2140 nm) is a pulsed.34. Prospective and randomized studies were also performed to compare the results achieved with ILC with those of other laser techniques (33) and TURP (30. However. 37. reported on a series of 97 patients with severely symptomatic BPH.

gov/entrez/query. The use of the neodymium YAG laser in prostatotomy.42). Perlmutter AP. J Endourol 1991. 5. http://www. http://www. Braslis KG. Roskamp D.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542818& dopt=Abstract Anson K.ncbi. Transurethral ultrasound-guided laser-induced prostatectomy: objective and subjective assessment of its efficacy for treating benign prostatic hyperplasia. Ganabathi.nih. REFERENCES Kandel LB. Lasers in Urologic Surgery. A multicenter.experimental and first clinical results. Burt J. Other lasing techniques. Perachino M. Transurethral laser prostatectomy: Creation of a technique for using the Neodymium-Yttrium. Levinson AK. St Louis.43:149-153.nlm. Assimos DG. Watson G.69:603-608.4.nlm.133:331A. 8.ncbi.46:305-310. Woodruff RD et al. The optimisation of laser prostatectomy. Childs Laser ablation of the prostate in patients with benign prostatic hypertrophy. Harrison LH. there are no specific limitations to the procedure. Urology 1994. 4. with an incidence of approximately 10% (38. Eur Urol 1994. Price 3. 10. Nawrocki J.nlm. Bolton DM. Hofstetter A. II.ncbi. Tansey LA. 1994.nlm.ncbi. McCullough DL. SPIE Proceedings 1991. eds. although the presence of a prostate gland over 100 mL is a relative contraindication in urologists' early experience (38).gov/entrez/query. 10. Transurethral laser prostatectomy using a right-angle delivery system. In: Smith JA et al. Greskovich FJ.46:155-160.fcgi?cmd=Retrieve&db=PubMed&list_uids=7515349& dopt=Abstract Costello AJ. Lasers Surg Med 1992. Sirls L.147:346A. 4. Kabalin JN.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=1379101& dopt=Abstract Leach Ricciotti G.40. prospective study of endoscopic laser ablation versus transurethral resection of the prostate. Canine transurethral laser-induced prostatectomy.5 CONCLUSIONS Laser prostatectomy should be advised for patients who are: • receiving anticoagulant medication • unfit for TURP (side-fire or ILC) • wanting to maintain ejaculation (side-fire or ILC) • holmium laser prostatectomy is a viable alternative to TURP and irrespective of any anatomical configuration. Urology 1995. 11. Buckley J. Stein B. Hessel S. Dixon C. Paterson P. the technique is a surgical procedure that requires significant endoscopic skill and cannot be considered easy to learn. Muschter R. Cromeens DM. Retrograde ejaculation occurs in 75-80% of patients. Urology 1994.Post-operative dysuria is the most common complication.Aluminium-Garnet (YAG) laser in the canine model. Patients on anticoagulant medication and those with urinary retention can be safely treated (43). USA: Mosby. Lawrence W.fcgi?cmd=Retrieve&db=PubMed&list_uids=7544932& dopt=Abstract 2. however. J Urol 1985. Dmochowski R.nih. J Urol 1986.fcgi?cmd=Retrieve&db=PubMed&list_uids=7985315& dopt=Abstract Cowles RS 3rd. no post-operative impotence has been reported (38). Scannapieco G.nih. Stein BS.5:145-149.4.133:110A. Interstitial laser prostatectomy . A prospective randomized comparison of transurethral resection to visual laser ablation of the prostate for the treatment of benign prostatic hyperplasia. No major complication has been described. 7. McCullough DL. http://www. Shanberg AM. 12. http://www. 6. J Urol 1992. 9. http://www. http://www. Lepor H. Urology Kirby R.6 1. Bowsher WG. Puppo P. Johnson DE. Fowler C.44:856–861. Baghdassarian R. UPDATE MARCH 2004 45 .fcgi?cmd=Retrieve&db=PubMed&list_uids=7509525& dopt=Abstract Muschter R.nih. 4.nih. randomized. Outpatient visual laser-assisted prostatectomy under local anesthesia.ncbi. the size of the prostate that can be treated depends on the experience and patience of the urologist.12:254-263. Pathologic changes occurring in the prostate following transurethral laser prostatectomy.nlm. Johnson DE. p. Br J Urol 1992. Laser-tissue interaction. 13.nih. Zabbo A. Conversely.

nlm.nlm. De Wildt M.] Acta Urol Ital 1998. Br J Urol 1995. Bite G. Jichilinski P et al. 30. http://www. Asopa R. J Endourol 1997. Urodynamic assessment in the laser treatment of benign prostatic enlargement.ncbi.155:316A.nlm. 24. Paris. Oswald M. 529-540. Muschter R. 15. Interstitielle Thermokoagulation (ITK) von De Wildt MJ. Abrams PH. http://www.nih.35:138-146. World J Urol 1995. Neodymium:YAG laser coagulation prostatectomy: 3 years of experience with 227 patients. http://www. Long-terms results of randomized laser prostatectomy vs. World J Urol 1995.ncbi. Kabalin JN. Urodynamics and laser prostatectomy. Whitfield HN. eds.fcgi?cmd=Retrieve&db=PubMed&list_uids=8535680& dopt=Abstract Cannon A. 18. 19. http://www.11:207-209. Side-firing neodymium:YAG laser prostatectomy. Laser prostatectomy. Bite G.ncbi. Griffiths K. J Urol 1996. Interstitial laser therapy of benign prostatic hyperplasia. Laser prostatectomy performed with right angle firing neodymium: YAG laser fiber at 40 watt power settings. 22. Sirls LT.157(Suppl 1):41.nlm.155:310A. Altwein JE.nih.157:42A. 16.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933808& dopt=Abstract Muschter R. Chan SL. Hofstetter A.ncbi. Proceedings of the Fourth International Consultation on BPH. Plymouth: Health Publications. July 1997.nih.155:181-185. J Urol 1996. Rosier PF. Khoury S et al.nlm. http://www. TURP: modification of laser prostatectomy technique with biodegradable stent insertion. [Italian] Kabalin JN.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9181452& dopt=Abstract Costello AJ. Urology (letter) 1997.nih. Eur Urol 1999.14. Kahn R et al. Endourol 1996.10 (Suppl 1):S191. Urology 1996. J. Whitfield H.76:604-610. 25. 1998. Initial results of a randomized trial comparing interstitial laser coagulation therapy to transurethral resection of the prostate. 20. 21.12(Suppl 1):44.ncbi.nih.plymbridge.nlm. Wijkstra H.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542968& dopt=Abstract Choe JM. de la Rosette 23. Fay R. Debruyne Perachino M.13:134-136. http://www. Schmidlin F. http://www. J Urol 1996. Kabalin JN. Doll S. Neodymium: YAG laser coagulation prostatectomy for patients in urinary A randomized prospective multicenter study evaluating the efficacy of interstitial laser coagulation.155:318A.ncbi. Crowe HR. Combination of thermocoagulation and vaporisation using a Nd:YAG/KTP laser versus TURP in BPH treatment: preliminary results of a multicenter prospective randomized study.nih.nlm. High-energy visual laser ablation of the prostate in men with urinary retention: pressure flow analysis. 29.35:147-154. Costello Cho G et al. Fortunato P et al.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334638& dopt=Abstract Hofstetter A. [Prostatectomia laser con metodica side-fire: risultati a distanza di 5 anni. 46 UPDATE MARCH 2004 . Puppo P. Technique and results of interstitial laser coagulation. De la Rosette JJ. J Urol dopt=Abstract Stein BS. 28. Bruschter R et al.nih.nih. Perlmutter A. Eur Urol 1999. A new technique of subsurface and interstitial laser therapy using a diode laser (wavelength = 1000 nm) and a catheter delivery device.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490827& dopt=Abstract Te Slaa E. In: Denis L. Diana M.ncbi. 27. Lasermedizin 1991. http://www.ncbi. 31. Results of interstitial laser coagulation of the prostate.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542962& dopt=Abstract Bhatta KM. J Urol 1996. J Urol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933807& dopt=Abstract Kabalin JN. http://www. Schettini M.

nih. Laser prostatectomy with the holmium:YAG laser.ncbi. Whitfield HN. the following parameters should be obtained: • I-PSS. prospective study. Are contact laser. Eur Urol 1999.fcgi?cmd=Retrieve&db=PubMed&list_uids=9376851& dopt=Abstract 4. Cass CB.fcgi?cmd=Retrieve&db=PubMed&list_uids=7633476& dopt=Abstract Chun SS. Denstedt JD. J Endourol 1995.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9586609& dopt=Abstract Le Duc A. Thermocoagulation au laser de l’adenome de la prostate par voie interstitielle. 40. 36. In: Muller G et al. 42. Ann Urol (Paris) 1997. Janetschek G. http://www.9(Suppl 1):S149.nlm. Laser-induced Interstitial Thermotherapy.cfm?fuseaction=SearchResultsVolume&keywords=Laser-induced%20 Interstitial%20&searchtype=SearchResultsVolume&quicksearch=1&CFID=353971&CFTOKEN=68929120 Horninger W.nih. Hofstetter A. Kabalin JN.32. 38.2 Procedure A beam of ultrasound can be brought to a tight focus at a selected depth within the Cresswell M.nlm.35:155-160. Desgrandchamps F. Holmium: YAG laser resection of the prostate (HoLRP) versus transurethral electrocautery resection of the prostate (TURP): a prospective randomized. Razvi HA. Holmium: YAG laser resection of the prostate (HoLRP) for patients in urinary retention.1 Assessment No specific diagnostic work-up prior to transrectal HIFU therapy is 37.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933809& dopt=Abstract Gilling PJ. 1995. http://bookstore.5 Transrectal high-intensity focused ultrasound (HIFU) 4. 43. urodynamicbased clinical trial. 35. including quality of life • Free uroflowmetry. http://www. Fraundorfer MR.nlm. http://www. including post-void residual urine volume • Serum PSA • TRUS • Pressure-flow study advisable. Luppold T. Henkel TO. Br J Urol 1997. Perlmutter AP et al.ncbi. Fraundorfer MR. J Urol 1997. Gilling PJ.nlm. High power interstitial laser coagulation of benign prostatic hyperplasia. 51: 573-577. 34.fcgi?cmd=Retrieve&db=PubMed&list_uids=9157819& dopt=Abstract Le Duc A.31:255-263. the predominant UPDATE MARCH 2004 47 .fcgi?cmd=Retrieve&db=PubMed&list_uids=9118394& dopt=Abstract Gilling PJ. Bartsch G. Anidjar M.fcgi?cmd=Retrieve&db=PubMed&list_uids=9180936& dopt=Abstract Muschter R. If the site-intensity is set below the tissue cavitation threshold.5. Reissigl A. J Endourol 1996.nih. Fraundorfer 416-423.spie. A randomized. Holmium laser resection of the prostate.ncbi. J Endourol 1995. Gilling PJ.nlm. Muschter R. pp. Watson G. Combination Holmium and Nd: YAG laser ablation of the prostate: initial clinical experience. thus producing a region of high energy density within which tissue can be destroyed without damage to the overlying or intervening structures (1-3). 41. Cass CB.1:217-221. Kabalin JB. interstitial laser. de la Rosette Kabalin http://www. Holmium laser resection of the prostate (HoLRP) versus neodymium: YAG visual laser ablation of the prostate (VLAP): a randomized prospective comparison of two techniques for laser prostatectomy. Urology 1998. Bellingham: SPIE Press.80(Suppl 2):A773.ncbi. However. Alken P.ncbi. J Endourol 1997. 33. Gilling PJ. Transurethral and transperineal interstitial laser therapy of BPH. Fraundorfer MR. http://www. Teillac P. and transurethral ultrasound-guided laser-induced prostatectomy superior to transurethral prostatectomy? Prostate 1997. http://www. Cresswell MD.157:149A.nih. Mackey MJ. Malcolm A. http://www. Strasser H.9:151-153. The use of an interstitial diode laser (Indigo) in laser prostatectomy. Greschner M.ncbi. Tech Urol 1995. 39.nlm.5.10(Suppl 1):S197. Sroka R. The Holmium YAG laser in the transurethral resection of prostate.31:27-37.ncbi. Malcolm AR.

an ellipsoidal tissue volume approximately 2 mm in diameter and 10 mm in length is destroyed (1-3). After therapy. 4.5.5-4. 80% of patients were obstructed and a further 20% were in the intermediate zone according to the Abrams-Griffith nomogram. the maximum site intensity was set at 2.5) at 12 months (5).7) to 13.5. The second severe complication was a thermolesion of the rectum requiring surgical intervention.5.1) to 12. the post-void residual urine volume decreased from 131 (± 120) mL to 48 (± 41) mL at 6 months and to 35 (± 30) mL at 12 months. (12).1 (± 6.4 (± 4. The AUA symptom score reduced from 24.2 mL/s after 3 months.5 Urodynamics The urodynamic effect of transrectal HIFU therapy has been studied by Madersbacher et al. Haematospermia for 4-6 weeks is observed in up to 80% of sexually active men. 4.200 W/cm2. The most prominent side-effect is prolonged urinary retention. The focal length (2. This complication led to reconstruction of the filling apparatus and the probe such that the problem can now be reliably avoided. transrectal HIFU is well-tolerated but requires general anaesthesia or heavy intravenous sedation.4 (± 5. In the same time period.4 Outcome In June 1992. detrusor pressure at Qmax and linear passive urethral resistance relation was observed. After HIFU.9 (± 4.5. Thirty patients underwent urodynamic investigations (pressure-flow study) before and after a mean of 4. half of the patients were in the equivocal zone and 13% were clearly unobstructed. Bihrle et al. Pre-operatively. Within the same time period.6). (13). a statistically significant decrease in maximum detrusor pressure. Ebert et al.5. Two severe complications have been reported. In clinical use.5 months following HIFU therapy. and patients frequently discharge two to three drops of blood prior to micturition for several weeks.260 to 2. In the initial US series. incontinence or the need for blood transfusion have been reported in the literature.7 Durability The long-term outcome of 80 patients with a follow-up of up to 4 years and a minimum follow-up of 2 years 48 UPDATE MARCH 2004 .1. Within the HIFU beam focus. (7) reported on experience with 15 patients and a follow-up of 90 days. This technique is known as high-intensity focused ultrasound (HIFU).0 mL/s and the post-void residual urine volume decreased from 154 mL to 123 mL (7). 20 of whom were followed up for 12 months (5). several hundred patients have been treated with the Sonablate® at various sites. n = 33) and 13.7) at 6 months and to 10.5 (± 4.9 to 7. It was caused by inadvertent overfilling to 500 mL and subsequent rupture of the condom that covered the ultrasound probe.5. although some patients report a decreased ejaculate volume. however. a multiplicity of laterally or axially displaced individual lesions is generated by physical movement of the sound-head. Theoretically the prostate can be ablated by HIFU via a transabdominal or transrectal route.6 mL/s to 15.0 MHz transrectal transducer for imaging and therapy. 4.therapeutic effect is the induction of heat. As a consequence.300 W/cm2. Similarly. The site intensity can be varied from 1. The Qmax increased from 8.6) mL/s (6 months. the post-void residual urine volume decreased from 182 mL to 50 mL and the I-PSS from 17. The authors concluded that the capability of transrectal HIFU to reduce bladder outlet obstruction was moderate (12).3 mL/s to 14. there is little data on sexual function. To date. In order to create a clinically useful volume of necrosis.8 (± 2. n = 20). who studied in detail the early post-operative morbidity of several less invasive procedures. Clinical data are only available for one device. only transrectal HIFU devices are applied for the indication of BPH.000 W/cm2. No cases of urethral strictures. As a consequence. (8) treated 35 patients. The Qmax increased from 7. The source for HIFU is a piezoceramic transducer. The Qmax increased from 9. The histological effect of transrectal HIFU therapy using the Sonablate® on the canine and human prostate has been studied in detail (1-3. the Sonablate® (1-4). Urinary tract infection occurs in around 7% of patients. Haematospermia lasting for a maximum of 4-6 weeks is seen in the majority of sexually active patients. lasting for 3-6 days.0 cm) is dependent upon the crystal used.6 Quality of life and sexual function There are no reliable data on quality of life after transrectal HIFU except from a study by Schatzl et al. This was most likely caused by using an inappropriately high-site intensity exceeding 2. Retrograde ejaculation and erectile dysfunction can be safely avoided. Several other sites have confirmed these data (9-11). perforation of the descending colon approximately 50-60 cm above the treatment zone occurred.5) mL/s (12 months. an international Phase II clinical trial was initiated to evaluate the safety and efficacy of transrectal HIFU therapy for patients with LUTS due to BPH. In one patient.3 Morbidity/complications In general. yet 37% were still obstructed according to the Abrams-Griffith nomogram. which has the property of changing its thickness in response to an applied voltage (1-3). 4. transrectal HIFU should not be considered for severely obstructed patients or those with an absolute indication for surgery. The initial report of the study included 50 patients. This system uses the same 4. 4. eight of whom had urinary retention.

however. No data are yet available from randomized. hinders a reliable statement concerning patient Application of Newer Forms of Therapeutic Energy in Urology. Lynch TH. 1995. A similar trend. 6.has been studied (14). Marberger M. yet a few selection criteria have been identified. Fitzpatrick JM. Madersbacher S.9 CONCLUSIONS Transrectal HIFU therapy is the only technique that provides non-invasive tissue ablation. Madersbacher S.5:147-149.03) (14). Madersbacher S. http://www.ncbi. 4.44:146-149. Hood JP. Smith JM.(higher treatment failure rate) • Absolute indication for surgery. Long-term efficacy is http://www. Curr Opinion Urol 1996. Marberger M. Tissue ablation in benign prostatic hyperplasia with high intensity focused ultrasound. which did not reach statistical significance. Applications of high energy focused ultrasound in urology. In: Marberger M ed.nih. 115-136.nlm.ncbi. Improvement of urinary symptoms is in the range 50-60% and Qmax increases by a mean of 40-50%.nih. Susani M. http://www. http://www. Marberger M.3 months (range: 13-48 months).fcgi?cmd=Retrieve&db=PubMed&list_uids=8587227& dopt=Abstract Mulligan ED. Foster RS. Madersbacher S. with a treatment failure rate of approximately 10% per year. 2.5. Ackermann R. Marberger M. Keio J Med 1995. 4.nlm. High-intensity focused ultrasound in the treatment of benign prostatic hyperplasia. Saddeler D. Oxford: Isis Medical Media. Djavan B. Minimally invasive therapy in BPH. general anaesthesia or at least heavy intravenous sedation is required. Cancer Res 1995.nlm. Kratzik C. Effect of high-intensity focused ultrasound on human prostate cancer in vivo. Graefen M. Marberger M. Mulvin D. Pedevilla M. High-intensity focused ultrasound for prostatic tissue ablation. Sanghvi NT.6:28-32.fcgi?cmd=Retrieve&db=PubMed&list_uids=7525992& dopt=Abstract Madersbacher S.nlm. Curr Opinion Urol 1995. Br J Urol 1997.ncbi.05) and lower grades of urodynamically documented bladder outlet obstruction (p = 0. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542168& dopt=Abstract Bihrle High-intensity focused ultrasound (HIFU) in the treatment of benign prostatic hyperplasia (BPH).fcgi?cmd=Retrieve&db=PubMed&list_uids=9052466& dopt=Abstract 3.nlm.10 REFERENCES 1. 4. http://www. 9.ncbi.151:1271-1275.8:17-26. Vingers L. 8. Madersbacher S. 5.fcgi?cmd=Retrieve&db=PubMed&list_uids=7512658& dopt=Abstract Ebert T.nih. controlled trials.nih. http://www.5. J Urol 1994. UPDATE MARCH 2004 49 . Therapeutic applications of ultrasound in urology. Miller S.ncbi.79:177-180.isismedical. Greene D. Marberger M. Susani M. was noted for individuals with a higher Qmax and lower post-void residual urine volume. Curr Opinion Urol 1998. High intensity focused ultrasound for the treatment of benign prostatic hyperplasia: early United States clinical experience.nih. Patients with one or more of the following criteria are unsuitable for transrectal HIFU therapy: • Prostates with dense calcifications (possibility of tissue cavitation) • Large prostates (> 75 mL) • Rectum to bladder neck distance over 40 mm • Large middle lobes • Higher grades of bladder outlet obstruction (BOO) .8 Patient selection The fact that only a handful of clinical studies with a limited number of patients have been published. J Urol 1994. Donohue JP. Thirty-five men (43.8%) underwent TURP due to an insufficient therapeutic response during the 4-year study period. Schmitz-Drager The retreatment-free period was significantly longer for patients with a pre-treatment average flow rate of more than 5 mL/s (p = 0. The mean follow-up of the study population (excluding patients who crossed over to TURP due to insufficient therapeutic response) was 41.

fcgi?cmd=Retrieve&db=PubMed&list_uids=9052465& dopt=Abstract Madersbacher S. Stulnig T.fcgi?cmd=Retrieve&db=PubMed&list_uids=8977064& dopt=Abstract Schatzl Randomized clinical trials TUNA® has been compared with TURP in one trial (8) with 12-month follow-up data.nih. Murai M. Schmidbauer CP. Post-operative urinary retention is seen in 13.ncbi. Adverse events.6. http://www. there was a significant decrease in AUA symptom score and bother score.nlm.6. These data are statistically significantly better than at baseline and surpass the expected placebo effect.ncbi.6 TUNA® 4.6.3 Morbidity/complications Is usually performed as an out-patient procedure under local anaesthesia. 4. urinary tract infection or strictures. Br J Urol 1997. Lang T. such as bleeding.2 Procedure The TUNA® device delivers low-level. There is no convincing evidence that prostate size is significantly reduced following TUNA® (7-9). Baba S.fcgi?cmd=Retrieve&db=PubMed&list_uids=10828669& dopt=Abstract 4. 4. http://www. Eur Urol 2000. 12. radio-frequency energy to the prostate via needles inserted transurethrally (1). Djavan A recent report with 5 years follow up in 188 patients demonstrated a symptomatic improvement of 58% and an improvement in flow rate of 41%. dysuria.1 Assessment No specific diagnostic work-up prior to TUNA® is necessary. 4. J Endourol 1997.nlm. http://www.nlm.nih. Marberger M. http://www.37:687-694. Early experience with highintensity focused ultrasound for the treatment of benign prostatic hyperplasia. a statistically significant decrease in maximum detrusor pressure or detrusor pressure at Qmax was 21. Klingler CH. The symptomatic improvement reported ranged from 40-70%. Improvements in Qmax vary widely from 26-121% in non-retention patients.158:105-111.2% required additional treatment (8). Gleave ME. Improvement in Qmax was significantly higher after TURP than after TUNA®. Goldenberg LG. Continence status is not affected. although intravenous sedation is required in some patients (1).nih.6% of patients and lasts for a mean of 1-3 days.nih.4 Outcome Several non-randomized clinical trials have documented the clinical efficacy of this procedure with a fairly consistent outcome (3-7).3-41.ncbi.nlm. 90-95% of patients are catheter-free (1). Nakamura K.10.6. 50 UPDATE MARCH 2004 . Marich KW. Irritative voiding symptoms lasting up to 4-6 weeks are frequently present (2). In all studies. 11. erectile dysfunction. 4. were more frequent in the TURP arm. Eur Urol 1996. Madersbacher S. J Urol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=9181450& dopt=Abstract Sullivan LD. Marberger M. 13. Tachibana M. The early postoperative morbidity of transurethral resection of the prostate and of four minimally invasive treatment alternatives.nlm. Long-term outcome of transrectal high intensity focused ultrasound therapy for benign prostatic hyperplasia. within 1 week. In both treatment arms. 14. High-intensity focused ultrasound energy for benign prostatic hyperplasia: clinical response at 6 months to treatment using Sonablate 200™.ncbi.nih. The urodynamic impact of transrectal high intensity focused ultrasound on bladder outflow obstruction.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186334& dopt=Abstract Madersbacher S.11:197-201.6 Impact on bladder outflow obstruction The impact of TUNA® on bladder outflow obstruction as assessed by pressure-flow studies was determined in seven clinical studies (7-13). Schatzl G. McLoughlin MG. Schatzl G. although improvements were slightly higher in the TURP arm. yet a number of patients remained in the obstructed range after TUNA® therapy.ncbi.79:172-176.30:437-445. Marberger M. Saito S.

fcgi?cmd=Retrieve&db=PubMed&list_uids=11223750& dopt=Abstract Bruskewitz R. A prospective randomized 1-year clinical trial comparing transurethral needle ablation to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia. multicenter US study.nih. Shumaker BP. Goldwasser B. Lang T.nih. Ekman P. Fitzpatrick JM. Eur Transurethral needle ablation of the prostate for the treatment of benign prostatic hyperplasia: a collaborative multicentre study.7 Durability Several authors have reported on the long-term efficacy of the TUNA® procedure.fcgi?cmd=Retrieve&db=PubMed&list_uids=12814680& dopt=Abstract Rosario DJ.158:105-110. http://www. Minardi D. Marberger M. Galosi AB.nih.ncbi. Safety and efficacy of transurethral needle ablation of the prostate for symptomatic outlet obstruction. TUNA® is not suitable for patients with prostate volumes exceeding 75 mL or isolated bladder neck obstruction. Perez-Marrero R.80:128-134. Jungwirth A.80:579-586. Urol Int 2001. Giammarco L.ncbi. Bruskewitz RC. Transurethral needle ablation (TUNA). Transurethral needle ablation (TUNA) of the prostate: clinical experience with two years’ follow-up in patients with benign prostatic hyperplasia (BPH). 5.157:98-102. Schulman CC. UPDATE MARCH 2004 51 . Long-term follow-up data exceeding this time period are not yet http://www. Roehrborn CG.ncbi. Naslund MJ. Improvement in Qmax exceeding 50% was seen in 53% of patients after 36 months. 4. Lynch TH. 4.nlm.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9352697& dopt=Abstract 2.6. Wiklund P. Yehia M. Br J Urol 1997.nlm. Shumaker BP. and there is limited evidence of long-term efficacy. Muzzonigro G. 4.ncbi. It results in an improvement of urinary symptoms in the range 50-60% and Qmax increases by a mean of 50-70%. Perez-Marrero R. Chapple CR. Cristalli AF. Br J Urol 1997.nlm. Within 1 year.35:119-128. Ten patients (20%) underwent TURP because of an insufficient therapeutic response (1).6. Urology 1998. Pressure-flow studies in men with benign prostatic hypertrophy before and after treatment with transurethral needle ablation. Issa MM.8 Patient selection Few selection criteria have been identified. Woo H. Issa MM. A critical review of radiofrequency thermal therapy in the management of benign prostatic hyperplasia.nih. J Urol 1997.66:89-93. Zlotta AR. Eardley I.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933805& dopt=Abstract Schatzl G. Naslund MJ. Garafolo F. Maehlum O.nih.44:89-93.ncbi.159:1588-1593. Hastie KJ. Long-term evaluation of transurethral needle ablation of the prostate (TUNA) for treatment of symptomatic benign prostatic hyperplasia: clinical outcome up to five years from three centers.nih. Transurethral needle ablation for benign prostatic hyperplasia: 12-month results of a prospective. 8 9.6.nlm. Pillai M.nlm. Clinical efficacy has been proven in only one randomized controlled trial.ncbi.ncbi. J Urol J Urol 1998. Giannakopoulos X. http://www. Chapple CR.10 REFERENCES 1. Eur Urol 1999.9 CONCLUSIONS TUNA® is a simple and safe technique and can be performed under local anaesthesia in a significant number of patients.4. (14) recently presented 3-year follow-up data on 49 patients after TUNA®. Oesterling JE. http://www. 3. Ostrem T. Woo Frick J. Issa MM. positive results can be translated into percentages ranging from 5-42% (1). http://www. Oesterling JE.51:415-421. 7. Madersbacher S.ncbi. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=9554360& dopt=Abstract Zlotta AR. Potts KL. 6. Cutinha PE.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9510346& dopt=Abstract Schulman CC. http://www. Schulman et al.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186334& dopt=Abstract Ramon J. The early postoperative morbidity of transurethral resection of the prostate and of four minimally invasive treatment dopt=Abstract Roehrborn CG. Narayan P.

A treatment catheter is connected to the module and inserted into the prostatic urethra. the retrograde ejaculation rate ranges from 0-11%.ncbi. 4. The majority of data in the literature on thermotherapy has been based on the Prostatron® device. haematuria is noticed. 11. and Targis® ( Occasionally.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=8916114& dopt=Abstract Campo B. Tamaddon K. Only two papers mention erectile dysfunction following thermotherapy (incidence 0. the characteristics of the applicators differ.fcgi?cmd=Retrieve&db=PubMed&list_uids=9187689& dopt=Abstract Steele GS.4 Morbidity Morbidity following TUMT is an important issue. Neurourol Urodyn 1996. In contrast to the low-energy protocol.nih.8-5%) (7. On a conceptional basis. Sweden).7. Also incorporated in the catheter are one or more temperature sensors that differ in the way in which they measure temperature. Fluid channels surrounding the catheter provide urethral Issa MM.ncbi. http://www. The similarity in catheter construction consists of the presence of a microwave antenna positioned in the tip of the catheter just below the balloon. but not usually for longer. http://www.1 Assessment Diagnostic endoscopy is essential because it is important to identify the presence of an isolated enlarged middle lobe or an insufficient length of the prostatic urethra. Eur Urol 1998.nlm. 12. 4. J Urol 1997.15:619-628. while for high-energy protocols. http://www. The main difference between the devices available is the design of the urethral applicator. No tissue sloughing occurs and urinary retention is expected in up to 25% of patients (2-6). Most patients experience perineal discomfort and urinary urgency for several days after treatment. Sleep Urology 1997. but subsequently higher energy levels were used to improve treatment outcomes and response rates. tens of thousands of patients worldwide have been treated with the Prostatron® device.10.nlm. 4.0.7. Apart from differences in the construction of the catheter. a company considered to be the pioneer of microwave thermotherapy.49:847-850. http://www.7 TUMT 4. For patients treated with low-energy protocols. ProstaLund® (Lund Systems. 13.2 Procedure TUMT is a registered trademark of Technomed Medical Systems (France). France). To date. Low-energy TUMT is well-tolerated by patients. 33(Suppl 1):148. A study of the efficacy and safety of transurethral needle ablation (TUNA®) treatment for benign prostatic hyperplasia. Transurethral needle ablation (TUNA) of the prostate: a clinical and urodynamic evaluation.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=8683692& dopt=Abstract Millard RJ.3 The microwave thermotherapy principle Microwave thermotherapy devices consist of a treatment module that contains the microwave generator with a temperature measurement system and a cooling system. J Urol 1996. High-energy treatment is also well-tolerated.7. Zlotta AR. a catheter may be necessary for an average of 7 days. 14.8). Corrada P. this figure increases up to 44%.nih. USA). the average catheterization time is 2 weeks. they are all similar in delivering microwave energy to the prostate with some type of feedback system. Bergamaschi F. In these cases. although pain medication needs to be administered to most patients prior to or during therapy. urinary retention is usual in patients treated with high-energy TUMT. Initial experience focused on low-energy protocols.nlm. Ordesi G. Other thermotherapy devices have also been developed: Prostcare® (Brucker. subjective and urodynamics Low-energy protocols: The standard operating software for the Prostatron® is version 2. and remarkably 52 UPDATE MARCH 2004 .nlm. Transurethral needle ablation (TUNA™) of the prostate: clinical experience with three years follow-up in patients with benign prostatic hyperplasia (BPH).nih. Harewood LM.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334612& dopt=Abstract Schulman Transurethral needle ablation of the prostate: report of initial United States experience. significantly affecting the heating profile (1. Transurethral needle ablation of the prostate: a urodynamic based study with 2-year follow-up. Outcome: objective.158:1834-1838. 4.

(18) and Devonec et al.14.2 to 7. there was no statistically significant differences between the 2 treatments in decrease in symptom score (66% vs 65%). increase in flow rate (74% vs. These objective and subjective improvements were sustained at 52 weeks. It was concluded from clinical experience that a shorter duration of treatment did not alter efficacy or decrease morbidity (22). After TURP and thermotherapy. SHAM-(placebo) controlled studies (4. the cooling temperature starts at a lower value (8oC) and is also linked to rectal temperature.6 at baseline to 5.17). On the other hand. When applying higher energy levels. This study showed significant improvement after both TUMT and TURP in symptom score. (3).9-13). (19) and demonstrated clinically significant improvements. a decrease in IPSS from 18. flow rate (34% vs. Qmax improved from 9. A randomized study comparing TUMT with TURP was performed by Dahlstrand et al. quality of life (IPSS) (69% vs.1 mL/s to 17.15).7%). with a decrease in Madsen symptom score from around 13 to 4. Symptomatic improvement is significant. changes to the Prostasoft® software have recently been reported. Van Cauwelaert et al.5 at 26 weeks. At 3-months of follow-up TRUS identified a prostatic cavity in almost 40% of patients. At 1 year of follow-up. post-void residual urine volume and grade of bladder outlet obstruction. an increase in maximum flow from 9.5 protocol differed significantly from former protocols.7%) or endoscopic surgery ( 37. the symptomatic improvement was 78% in the TURP group versus 68% in the TUMT group.9 and an increase in maximum flow rate from 8. the total treatment duration is shortened to only 30 minutes. international. with improvements observed following high-energy TUMT being in the same range as those seen after TURP. 4. there was a significant improvement in all clinical parameters. at six months. High-energy protocol: The first reports on the application of high-energy levels using Prostasoft® 2. with improvements in free flow being 100% and 69%.7 Durability Several studies using low-energy thermotherapy report on surgical retreatment rates for up to 1 year of 11% (25) and 10% (20). Energy delivery is now guided by the rectal temperature sensor via a feedback loop.1. Pace et al. 4. The mean increase in Qmax is 3-4 mL/s.7.1 mL/s at 26 weeks of follow-up.7. These improvements are noted from 6 weeks and persist over a period of 5 years (16.8 mL/s and cavities within the prostatic tissue of 54 of the 56 patients (95%). Qmax.5 High-intensity-dose protocol Although the results following high-energy TUMT are good. (26) found in 167 patients. representing a mean improvement of approximately 35% over baseline. (29) reported a 5-year retreatment rate in 45 patients of 84. while Daehlin et al. Recently Tsai et al. 47%). Only decrease in prostate volume was higher in the TURP group (51%) than in the PLFT group (30%) (28).1 to 5. The clinical efficacy of TUMT has been confirmed in several randomized. ProstaLund Feedback Treatment) (27).5. De La Rosette et al. In a prospective.4% with medication (46. the principle of stepwise energy increments was abandoned and the treatment was initiated at an 80 W energy level. the urethral temperature feedback system was also abandoned.9 to 16. On a conceptual basis. multicentre study against TURP. In this study. 64%). 4.4. a decrease in IPSS from 19. (24) found in 56 patients. Changes in objective parameters are less pronounced. Third. Secondly. the European BPH Study Group performed a multicentre study of 116 patients using high-energy TUMT (20). (30) found a retreatment rate after 5 years in 71 patients of 68%. 94%) or decrease in detrusor pressure at max. No serious complications occurred in either group.similar clinical results have been reported worldwide from several centres (2-4. Firstly. In a study by de la Rosette et al. More recently. the outcome seems improved and may eventually result in a more durable response.6 mL/s at baseline to 14. It was concluded that satisfactory results were obtained after both treatments.6 Prostatic temperature feedback treatment A treatment protocol with calculated tissue necrosis based on simultaneous intraprostatic tissue temperature has been introduced with the Prostalund Micowave apparatus (PLFT. This Prostasoft® 3. the mean Madsen score improved from 13. the so-called Prostasoft® 3. (11) reported only low retreatment rates with significant subjective and objective improvements.7. randomized.18) additional TURP was performed in only three out of UPDATE MARCH 2004 53 . (5. Although the decrease in symptom score was more pronounced after TURP (92%) than after TUMT (78%). but one patient in each group required another treatment. One-year follow-up results of a prospective randomized study comparing high-energy TUMT with TURP were reported recently (23).7. There appeared to be a good correlation between the presence of a cavity and uroflowmetry improvement (21). at 12 months. The best candidates for this treatment protocol appeared to be patients with moderate-to-severe bladder outlet obstruction.5 protocol can therefore be considered to be high-intensity-dose TUMT. and those with larger prostates (22). respectively. as measured by pressure-flow studies. Both groups had showed significant relief of bladder outlet symptoms. Finally.5 were published by de la Rosette et al.

175-186. 9.ncbi.nlm.nlm. 7. Urology 1994. J Endourol 1994. Mattiasson Pettersson S. The heat is on – but how? A comparison of TUMT devices.0): results of a randomized transurethral microwave thermotherapy versus sham study. http://www.150:1591-1596. 54 UPDATE MARCH 2004 . 5. Transurethral microwave thermotherapy for uncomplicated benign prostatic hyperplasia. Froeling FM.nlm.116 patients. In particular. Quality of life assessment in patients treated with lower energy thermotherapy (Prostasoft 2. Johnson 3. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=7518982& dopt=Abstract Servadio C. Bolmsjo M. de Wildt MJ.44:58-63.nlm.7. Debruyne FM. with a follow up of 2 years in 155 patients.7. de la Rosette JJ.ncbi. Good results with regard to catheter release have been obtained. Transurethral microwave thermotherapy (TUMT) in benign prostatic hyperplasia: placebo versus TUMT. Hallin A. Walden M. 4. J Urol 1997.nih.nih.8 Patient selection As the morbidity is relatively low and the treatment can be performed without anaesthesia. Sham versus transurethral microwave thermotherapy in patients with symptoms of benign prostatic bladder outflow obstruction.ncbi. with a success rate of 72% after 6 months in 29 patients (32). Non surgical treatment of BPH.fcgi?cmd=Retrieve&db=PubMed&list_uids=7692092& dopt=Abstract Dahlstrand C. 4. with sustained and durable long-term results.9 • • • CONCLUSIONS High-energy TUMT produces significant subjective and objective improvement. SIU report 3. Erlandsson Tomera KM.nih.nih. d’Ancona FC.fcgi?cmd=Retrieve&db=PubMed&list_uids=8535682& dopt=Abstract Ogden CW.ncbi. Ramsay JW. J Urol 1993.fcgi?cmd=Retrieve&db=PubMed&list_uids=7678047& dopt=Abstract De la Rosette JJM.28:83-89. Morbidity after TUMT consists mainly of the need for catheter drainage after treatment due to urinary retention. http://www.nlm. Br J Urol 1995. Transurethral microwave thermotherapy versus transurethral resection for symptomatic benign prostatic obstruction: a prospective randomized study with a 2-year follow-up.76:614-618. http://www. Deirsson G.7. Hendriks JC. 6. De Wildt et al.nlm. Debruyne FM. such patients with retention can benefit from this treatment. Wagrell L. Br J Urol 1996.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334613& dopt=Abstract Marteinsson VT. Rodrigues Netto N. Reddy P. Kiemeney LA. Eliasson T. Ejaculatory dysfunction after transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia. Carter SS.nlm. 1992. In a larger study of 200 patients. Claro JD. but with increased morbidity.fcgi?cmd=Retrieve&db=PubMed&list_uids=7524916& dopt=Abstract Francisca EA.10 REFERENCES 1. http://www. http://www. Due J. 4. Cortado PL. Sankey NE. In: Fitzpatrick JM ed. Ten years of clinical experience in transurethral hyperthermia to the prostate. Scand J Nephrol 1994. Hellerstein DK. Lancet 1993.nih. http://www. Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: results of the United States Prostatron Cooperative Study. (31) confirmed these findings.ncbi. Lynch JH.fcgi?cmd=Retrieve&db=PubMed&list_uids=7516577& dopt=Abstract 2. 4. patients in poor health are particularly good candidates for thermotherapy.nih. only 7% failed to respond (33). http://www. documenting five surgical interventions at 1-year follow-up in 85 patients–219. Alivizatos G. McKiel CF. Regan JB.ncbi.ncbi.341:14-17.78:564-572.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=8944513& dopt=Abstract Blute ML. High-energy TUMT is associated with improved objective results compared with low-energy TUMT.ncbi. Edinburgh: Churchill-Livingstone.

Azocar GH.fcgi?cmd=Retrieve&db=PubMed&list_uids=7683987& dopt=Abstract Terai J Urol 1996. Br J Urol 1993. Responders and nonresponders to transurethral microwave thermotherapy: a multicenter retrospective analysis. d’Ancona FC. 19. http://www. Tubaro A et al. Perrin P.159:1966-1972.ncbi. De Wildt MJ.5). Debruyne FM. http://www. Hubregtse M. 23. Transurethral microwave thermotherapy vs. Medina FI. Oishi K.10.ncbi.nih. 21. Curr Opinion Urol 1995. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8911365& dopt=Abstract Keijzers GB. J Urol 1997.nlm. Segura JW.5:3-9. Castillo OC. J Endourol.ncbi.7:255-259. (Congress report). Carter SS. Welling L. The Prostatron transurethral microwave device in the treatment of bladder outflow obstruction due to benign prostatic hyperplasia.ncbi. 14.nih. 13.nlm. Tomera KM.fcgi?cmd=Retrieve&db=PubMed&list_uids=9598499& dopt=Abstract De la Rosette JJ. http://www.158:120-125. 10:565-573. Philip T. 17.ncbi. Arai Y.ncbi. D’Ancona FC. J Urol dopt=Abstract De Wildt MJ.nlm.ncbi. Kirby RS. de la Rosette JJ.nlm. de la Rosette JJ.72:190-194. 22. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542159& dopt=Abstract Devonec M.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186336& dopt=Abstract UPDATE MARCH 2004 55 . Williams G. de la Rosette JJ. Aquirre CA.ncbi. Milroy Tubaro A. Yoshida Devonec M.fcgi?cmd=Retrieve&db=PubMed&list_uids=8648849& dopt=Abstract Devonec M. Francisca EA et al. de la Rosette JJ.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=8808890& dopt=Abstract De la Rosette JJ.156:1959-1963. d’Ancona FCH. Carter SS. 20.ncbi. SHAM: a prospective double-blind randomized study.nlm. 1996.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=7689386& dopt=Abstract Devonec M. Debruyne FM. de Wildt MJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=7563344& dopt=Abstract De la Rosette JJM. Hellerstein DK. Carter SS. Pressure/flow study analyses in patients treated with high-energy thermotherapy (Prostasoft 2. Clinical results of strategies to reduce morbidity in high energy transurethral microwave thermotherapy (HE-TUMT). High energy thermotherapy in the treatment of benign prostatic hyperplasia: results of the European Benign Prostatic Hyperplasia Study Group. 1997.nih. Witherow R.2:24-28. 11. Debruyne FM.nih. Microwave thermotherapy. d’Ancona FC. Carter SS. Houdelette P.fcgi?cmd=Retrieve&db=PubMed&list_uids=7691371& dopt=Abstract Van Cauwelaert RR. Transurethral microwave thermotherapy for benign prostatic hyperplasia: clinical results after a 1-year follow-up. J Urol 1996. Takeuchi H. http://www. Tubaro A. Patterson DE.156:97-101.ncbi.nih. Tubaro A. J Urol 1996. Colombeau P et al.nlm. Carter SS. High energy thermotherapy versus transurethral resection in the treatment of benign prostatic hyperplasia (BPH): results of a prospective randomized study with 1-year follow-up. Witjes WP. Transurethral microwave thermotherapy for the treatment of benign prostatic hyperplasia: preliminary experience. http://www. Three year follow-up of patients treated with lower energy thermotherapy (Prostasoft version 2. Review: transurethral microwave thermotherapy in benign prostatic hyperplasia. J Endourol 1993.nih. A multicenter study of SHAM versus thermotherapy in benign prostatic hypertrophy.nih. J Urol Francisca EA. 18. Onishi H. Int J Urol 1995.156:1428-1433. http://www. 15.0). http://www. AFU. Eur Urol 1993.154:1775-1778.nih. Hofner Hofner K. http://www.nlm.23:282-284. Hofner K.nlm. J Urol 1995. Debruyne FM. Kiemeney LA. Debruyne FM. de Wildt MJ. Francisca Tomera K. Long-term results of lower energy transurethral microwave thermotherapy. Blute ML.

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TUIP. which will depend on the type of treatment modality undertaken. Assessment includes: • I-PSS: recommended • Uro-flowmetry and post-void residual urine volume: recommended • Urine culture: optional • Histology: mandatory. Alpha-blocker therapy is a treatment option for patients with bothersome LUTS who do not have an absolute indication for surgical treatment. 8. 5. Patients should be reviewed at 6 months and then annually.4 Surgical management Following surgical treatment. Surgical management (TURP.2 Alpha-blocker therapy Patients should be reviewed after the first 6 weeks of therapy in order to determine their response. HoLRP is a promising new technique with outcomes in the same range as those of TURP. alpha-blocker therapy may be continued. Transrectal HIFU therapy is currently not recommended as a therapeutic option for elderly men with LUTS and is considered an investigational therapy. These patients may be candidates for urodynamic assessment and surgical treatment. 5. The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume. 9. Patients who fail treatment should have urodynamic studies with pressure-flow analysis. 6. If patients gain symptomatic relief in the absence of troublesome side-effects. 5. The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume. Significant post-operative morbidity. TUNA® is an encouraging technology as an alternative with acceptable results. patients may be seen within 6 weeks to discuss the histological findings and to identify early post-operative morbidity. 3. It is not recommended as a first-line surgical treatment for patients with LUTS. 5 ARI’s are an acceptable treatment option for patients with bothersome LUTS and an enlarged prostate (> 40 mL) and can be used when there is no absolute indication for surgical treatment. open prostatectomy) is recommended as first-line treatment for patients with complications due to BPH with (an absolute indication for treatment of) LUTS. 4. 7.1 Watchful waiting Patients who elect to pursue a WW policy should be reviewed at 6 months and then annually.8 1. 5. 5. provided there is no deterioration of symptoms or development of absolute indications for surgical treatment. FOLLOW-UP All patients who receive treatment require follow-up. Long-term follow-up should be scheduled at 3 months to determine the final outcome. RECOMMENDATIONS FOR TREATMENT The WW policy should be recommended to patients with mild symptoms that have minimal or no impact on their quality of life. UPDATE MARCH 2004 57 . The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume. 2.3 5-alpha-reductase inhibitors Patients should be reviewed after 12 weeks and at 6 months to determine their response. Patients who subsequently develop chronic retention will require evaluation of their upper tract by serum creatinine measurement and/or renal ultrasound. disappointing long-term data and higher costs have resulted in a substantial decline in the clinical use of lasers. but may have a role in the treatment of high-risk patient subgroups. Subsequent review is as for alpha-blocker therapy. 5. TUMT is an acceptable alternative to TURP and for those who prefer to avoid surgery or who no longer respond favourably to medication.4. provided there is no deterioration of symptoms or development of absolute indications for surgical treatment.

5. at 6 months. and then annually. 58 UPDATE MARCH 2004 . The following time schedule is appropriate for the majority of minimally invasive therapies: within 6 weeks.5 Alternative therapies Long-term follow-up is recommended because of concerns about the efficacy and durability of alternative therapies. at 3 months. Assessment includes: • I-PSS: recommended • Uroflowmetry and post-void residual urine volume: recommended • Urine culture: optional • Histology where available: mandatory. The intervals for follow-up will depend on the treatment modality employed.

Agency for Health Care Policy and Research European multicenter double-blind study to assess the efficacy and safety of Alfuzosin (5 mg twice daily) versus finasteride (5mg once daily) and the combination of both in patients with symptomatic BPH alpha reductase inhibitor American Urological Association Acute urinary retention BPH Impact Index bladder outlet obstruction benign prostatic enlargement benign prostatic hyperplasia blood urea/nitrogen computed tomography Danish Prostate Symptom Score velocity of detrusor contraction at 40 mL volume dihydrotestosterone digital rectal examination European Prostate Cancer Detection Study European Randomized Study of Screening for Prostate Cancer high-energy thermotherapy high-intensity focused ultrasound Holmium laser resection of the prostate International Continence Society International Prostate Symptom Score interstitial laser coagulation intravenous pyelography intravenous urography low-osmolar contrast material Linear Passive Urethral Resistance Relation lower urinary tract symptoms magnetic resonance imaging presumed circle area ratio Proscar Long-term efficacy and safety study Prostate.6. ABBREVIATIONS USED IN THE TEXT This list is not comprehensive for the most common abbreviations. Lung. Maximum flow rate prostate-specific antigen post-void residual volume average flow maximum flow mean flow for middle 90% of voided volume randomized controlled trial Receiver Operating Characteristics Quality of Life visual laser ablation time from Qmax until 95% of volume voided transrectal ultrasonography transurethral incision of the prostate transurethral microwave therapy transurethral needle ablation transurethral resection of the prostate transurethral electrovaporization Urethral Resistance Index visual laser ablation watchful waiting (deferred treatment) AHCPR ALFIN study ARI AUA AUR BII BOO BPE BPH BUN CT DAN-PSS dL/dt 40 DHT DRE EPCDS ERSPC HE-TUMT HIFU HoLRP ICS I-PSS ILC IVP IVU LOCM LinPURR LUTS MRI PCAR PLESS PLCO PPV PQSF PSA PVR Qav Qmax Qm90 RCT ROC QoL VLAP Tdesc TRUS TUIP TUMT TUNA® TURP TUVP URA VLAP WW UPDATE MARCH 2004 59 . Colorectal and Ovarian Cancer Screening Trial predictive positive value Prostate weight. Quality of life. Symptoms.